2013
Camp Save-A-Life
(Youth ages 10-14)
“Make new
friends while learning to keep your old friends safe!”
Camp Save-a-Life provides
youth with the opportunity to learn valuable disaster preparedness techniques
and leadership skills. Youth will become certified in CPR and First Aid, and
most importantly, they will have fun while learning how to keep their families
safe!
Monday, July
8, 2013 - Friday, July 12, 2013
Monday, July 15,
2013 - Friday, July 19, 2013
Monday, July 22,
2013 - Friday, July 26, 2013
Monday, July 29,
2013 - Friday, August 2, 2013
Monday, August
5, 2013 - Friday, August 9, 2013
Monday, August
12, 2013 - Friday, August 16, 2013
9:00 am - 3:00 pm: Red Cross House
40th
St. and Powelton Ave., Philadelphia, PA
Registration Deadline: Friday, June 7, 2013
*Please note: choose only ONE week for your child(ren) to attend
Space is limited. Applications are accepted on a first come, first
serve basis.
The Camp is free of charge and participants will be provided with a
snack and lunch daily.
You will become
certified in CPR and First Aid
|
Please submit completed
applications to:
Mike Kiley-Zufelt, Manger
of Community Resiliency,
or via email to: Mike.Kiley-Zufelt@redcross.org.
|
PARTICIPANT PROFILE
Last Name (Print):
___________________________________________________________
First Name (Print):
__________________________________________________ MI:______
Suffix:
(e.g. JR, SR, etc.)______________
Nickname:_________________________
Age: ____________
Date of Birth:______/_______/_____
month day year
Gender: Female Male T-shirt size: XS S M L XL
Home Address:
______________________________________________________________
City:
________________________________ State: __________ Zip Code: ______________
Home Phone:
_________________________ Cell Phone: ____________________________
Email:
_____________________________________________________________________
Grade: (in September 2012) 4TH 5TH 6TH 7TH 8TH 9TH
School
Name:_________________________________________________________________
City:
_________________________________ School District: _________________________
Camp Week: □ July 8th –
12th □ July 15th
– 19th □ July 22nd
– 26th □ July 29th
– August 2nd
□ August 5th -
9th □ August 12th
- 19th
EMERGENCY CONTACT INFORMATION
Parent/Guardian
Name:____________________________________
Relation: ___________________________
Address:
_____________________________________________________________________
City:
________________________________ State: __________ Zip Code: ______________
Home
Phone: ______________________________ Cell Phone: _________________________
Work
Phone: ______________________________ Employer: __________________________
Parent/Guardian
Name:____________________________________
Relation: ___________________________
Address:
_____________________________________________________________________
City: ________________________________
State: __________ Zip Code: ______________
Home
Phone: ______________________________ Cell Phone: _________________________
Work
Phone: ______________________________ Employer: __________________________
Additional Emergency Contact
If you (the parent/guardian)
cannot be reached in the case of an emergency, please list an additional person
whom we can contact. If you can’t be reached, this individual may be asked to
make medical decisions for your child on your behalf.
Name:____________________________________ Relation:
___________________________
Home Phone:
______________________________ Cell Phone: _________________________
Work Phone:
______________________________ Employer: __________________________
MEDICAL INFORMATION
Please fill out the following
questions to the best of your knowledge. Please indicate “no” in the space if
the participant has none of the conditions listed in that question.
1. Medications (Please include prescription and over-the-counter
medications.)
2.
Allergies (Please list any
allergies to medications, bug bites/stings, food, etc.)
3. Medical conditions in which we should know about (i.e. asthma,
diabetes, heart disease, recent surgery, past/present seizures.)
4.
Family history of diseases
(in case your child displays any symptoms.)
5. Are all immunizations up to
date? Yes
No
MEDICAL INSURANCE INFORMATION
Note: No one will be excluded from
participation due to the lack of health insurance.
Name of Insured (name on the
card):________________________________________________
Company or
Plan:___________________________________Phone_______________________
Address:
______________________________________________________________________
City:________________________ State: ____________________ Zip: __________________
Policy #
:__________________________________
Group # :__________________________
Primary
Secondary
This plan is considered (please
check on e of the following):
q HMO (Health Maintenance Organization
q PPO (Preferred Provider Organization Other: Please specify: ________________
Participant Agreement and Parental
(Guardian) Waiver/Consent
I, the undersigned, give my
permission for the below named youth to attend the 2013 American Red Cross Camp
Save-A-Life at the Red Cross House, 40th and Powelton Sts.,
Philadelphia, Pennsylvania from: □ July 8th – 12th □ July 15th – 19th □ July 22nd – 26th □ July 29th – August 2nd
□ August 5th
- 9th □ August 12th
- 19th.
In the event of an emergency, if neither
parent/guardian nor the person(s) on emergency contact section can be reached,
I hereby authorize the Red Cross Adult Staff, and/or hospital doctors/personnel
(if participant needs hospital care) to take any action deemed necessary for
the best interests of the below named youth for whom I am responsible.
I, the undersigned, know that
participation in certain activities of the American Red Cross Camp Save-A-Life
could be potentially hazardous. I will
not participate in any activities of the Camp Save-A-Life unless physically
able. I certify that my physical
condition will enable me to participate in the Camp Save-A-Life. Further, I agree to abide by any decision of
the staff relative to my ability to participate in any activity of the Camp
Save-A-Life.
I, the undersigned, give my
permission for my daughter/son to administer his/her own prescription and /or
non-prescription medication that s/he will bring to the American Red Cross Camp
Save-A-Life. I understand that the
American Red Cross and/or Red Cross staff will not be responsible for
dispensing, tracking, or administering these medications.
I, the undersigned, hereby agree
to abide by the rules and regulations of the American Red Cross and elect to
participate in the American Red Cross Camp Save-A-Life at my own risk, and in
consideration for being allowed to participate in the American Red Cross Camp
Save-A-Life, I do hereby release and discharge the American Red Cross, its
assignees, officers, agents, employees, and officials from any and all
liability (including, without limitation, personal injury and property damage)
that may be incurred by me (or my minor child) as a result of participation in
the American Red Cross Camp Save-A-Life, except where the same is caused by the
willful misconduct of the American Red Cross.
Participant Name:______________________________________________________________
Participant
Signature:___________________________________________________________
Participant Phone
Numbers:_________________________home_____________________cell
Date:__________________
Parent/Guardian
Name:__________________________________________________________
Parent/Guardian
Signature:_______________________________________________________
Parent/Guardian Phone
Numbers:_____________________home_____________________cell
Date:__________________
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