ONCOLOGY CAMPER
APPLICATION
by May 12, 2017
Return Application
to:
Camp Bring It On, Marilee Kontz, Sanford Children’s Camping Coordinator,
1305 W. 18th St., PO Box 5039, Sioux Falls, SD 57117-5039
(To be completed by parent/guardian)
Name: ___________________________________________________________________________________________
Last First Middle Initial
Birth Date ______ /_____ /_____ Age at camp _________ Sex: ❑ M ❑ F
Your child’s email address: ___________________________________________________________________________
Camper’s T-shirt Size: Child ❑ 6-8 (S)
Adult ❑ S
❑ 10-12 (M)
❑M
❑L
❑ XL
❑ 14-16 (L)
❑ XXL
Parent or Guardian:________________________________________________________________________________
Last First
Home address: ____________________________________________________________________________________
Number & Street City/State Zip
Home Phone: (___ )_____ -______ Work Phone: (____) ____ -_____ Mobile/Pager: (___) _____ - _____
Email address: ____________________________________________________________________________________
May we release your email address to other campers and staff? ❑ Yes ❑ No
Second Parent or Guardian: ________________________________________________________________________
Last First
Home address: ____________________________________________________________________________________
Number & Street City/State Zip
Home Phone: (___ )_____ -______ Work Phone: (____) ____ -_____ Mobile/Pager: (___) _____ - _____
Email address: ____________________________________________________________________________________
Person to be contacted in case of an emergency if parent(s)/guardian(s) cannot be reached:
Name: ____________________________________________ Relationship to camper:____________________________
Last First
Home Phone: (___ )_____ -______ Work Phone: (____) ____ -_____ Mobile/Pager: (___) _____ - _____
Insurance Information:
Do you carry family medical/hospital insurance? ❑ Yes ❑ No Name or person with insurance:______________________
If so, indicate carrier:_______________________________ Policy or group number: _____________________________
Carrier address:____________________________________________________________________________________
Name of family physician:__________________________________ Phone:____________________________________
Camper Health History
Information on this form is not part of the camper acceptance process,
but is gathered to assist us with providing appropriate care.
(This side to be filled in by parents/guardians of minors.)
Child’s Name: ____________________________________________________________ Age at camp: ______________
Last First
Cancer diagnosis/date of onset: ____ /_____ /_____ Type of cancer: _________________________________________
Is your child currently on treatment? _________________ If not, month and year of last treatment:___________________
Does your child have a central line? ❑ Y ❑ N If yes, Broviac (external) or Port (internal)?
Will it need to be flushed the week of camp? ❑ Y ❑ N
Operations or serious injuries (Please list dates): _________________________________________________________
Health History
Immunization
Diseases
Allergies
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___ Chicken Pox
________________________
___ Measles
________________________
___ German Measles
________________________
___ Mumps
________________________
___ Hay Fever
___ Penicilin
___ Other Drugs
________________________
________________________
___ Other (specify)
________________________
________________________
(Check if yes.)
(If yes, give approximate dates.) (If yes, give approximate dates.) (Check if yes.)
Frequent Ear Infections
Heart Defect/Disease
Convulsions/Seizures
Diabetes
Bleeding/lotting Disorders
Hypertension
Mononucleosis
Asthma
Tetanus
Booster
Polio
Diphtheria
Measles
Mumps
Rubella
Pertussis
Tuberculin
Chronic or recurring illness or medical condition:__________________________________________________________
Dietary restrictions:_________________________________________________________________________________
Other diseases:____________________________________________________________________________________
For Female:
Has this person menstruated? ____If not, has she been told about it?____ If so, is her menstrual history normal?____
If not, please explain:_______________________________________________________________________________
Medication during camp: Medications are dispensed at each meal and at bedtime. We would prefer to give
as many evening medications as possible with supper. If the evening medications must be given at bedtime,
please indicate this below.
Is there any sunscreen or bug spray your child cannot use?_________________________________________________
Name of Medication
Route
(Mouth, IV, SQ, etc.)
Attach additional sheet if necessary.
Dosages
Frequency
(include even/odd days)
Circle the time of
day to be given
AM PM NOON
BED
AM PM NOON
BED
AM PM NOON
BED
AM PM NOON
BED
AM PM NOON
BED
Important:
Mandatory Photo
Required
for ALL
CAMPERS
(Please attach
photo here)
Camper Questionnaire
(To be completed with the help of Mom or Dad)
Dear Camper. In order to help you have a great time at camp, we
would like to get to know you better. Please complete the following
questions. Please tell us some important things about yourself that
we can share with your counselors.
What is your name?______________________________________________
How old are you?________________________________________________
What grade in school are you?_____________________________________
Do you have brothers or sisters?____________________________________
If so, what are their names and how old are they?______________________
What is your favorite TV show or movie?______________________________
What are your favorite books or stories?_________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
What is your favorite food or candy?____________________________________________________________________
What are your favorite things to do at camp?
________ Swimming _________Riding _________ Horses _________ Dancing _________ Fishing ___________ Karaoke
________ Canoeing _________Riflery_________ Archery_________ Arts & Crafts
Have you been to other overnight camps? ❑ Yes ❑ No
If you have, which ones? ____________________________________________________________________________
What do you enjoy most about camp?__________________________________________________________________
Tell us something special that happened to you within the last year: __________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
What are you most looking forward to doing at camp? If there is anything that you would especially like
to do or learn at camp, please list it below and we will try to provide that experience for you.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
We can’t wait to see you at Camp Bring-It-On!
Parent/Guardian Questionnaire
This form must be completed and returned with the application.
Camper’s Name: ______________________________________________________ Age at Camp:__________________
Yes No
Is this his/her first time sleeping away from home? ______ ______
Does your child have any special concerns about attending camp
______ ______
or being away from home? ______ ______
Is he/she anxious/uptight around new faces/other children?
______ ______
Does your child require any special assistance?
(including walking aids, prosthetic devices, wheelchair transfers, or other
specialty equipment to make camp a successful experience.)
______ ______
Does your child have trouble controlling bladder or bowel movements? ______ ______
Does your child need assistance with personal hygiene?
______ ______
Does your child have any behavioral problems?
______ ______
Does he/she have any serious fears?
______ ______
Does your child have a history of: Difficulty sleeping (nightmares, sleepwalking or talking, or bed wetting)?
Please circle all that apply.
______ Has he/she experienced a death in the family or a friend in the last twelve months?
______ ______
Does he/she have a particular concern related to their diagnosis,
treatment and or change in appearance?
______ ______
If you answered yes to any of the above questions, please explain.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Is there anything you feel we should know about your child which will help make their week better?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Information on this page will be shared with staff
selected to work with your child at camp!
Camp Bring It On Conduct Agreement
• I,_______________________________ , agree to have fun at camp. In order to have fun at camp, I will respect
the other campers, Camp Bring It On Staff, Joy Ranch staff and the camp facilities. I will follow camp rules.
• I will be responsible for my own words and actions.
• I will only take medicine and/or treatments as directed by staff.
• If I display disrespectful, disruptive, or unruly behaviors or if I emotionally, verbally, or physically
threaten others, I will meet with the Camp Bring It On directors and may be sent home.
• If I am sent home, my parents will be responsible for picking me up or arranging transportation home.
• CELL PHONES WILL BE TURNED IN AT CHECK IN AND CAMPERS MAY USE AT FREE TIME.
______________________________________ Camper Signature _____________________________________________
Parent/Guardian Signature
______________________________________ Date
_____________________________________________
Date
CAMP BRING IT ON
SWIMMING/TUBING LIABILITY FORM
Camper Name: _________________________________________________________________________________
Opportunities your child may have while at camp bring it on include: Tubing, boating, riding on jet skis. Each child
will wear a life jacket.
Does your child have permission to participate in these activities?
Yes____________________________________________ No______________________________________________
Parent/Guardian:
Signature:______________________________________________________________________________________
Date:__________________________________________________________________________________________
Camper Health Evaluation
TO BE COMPLETED BY MEDICAL PROVIDER
I have examined (name of camper): ___________________________________________________________________
Date of exam: ________________________ (must be within 6 months of camp)
Participation level at camp:
Full participation
Age: _______________
Limited participation (circle one)
Activity restrictions: _______________________________________________________________________________
Height:____________________ Weight:____________________ Blood pressure: _______________________________
The applicant is under the care of a physician for the following condition(s): ___________________________________
_______________________________________________________________________________________________
Current treatment (protocol) at the time of this report: ____________________________________________________ _______________________________________________________________________________________________
_______________________________________________________________________________________________
Date of last treatment: Treatment to continue at camp: ____________________________________________________
What treatment/chemotherapy was given: ______________________________________________________________
Central line:
Yes
No
(circle one)
Will it need to be flushed the week of camp?
If yes,
❑ Yes
Broviac (external)
❑ No
or
port (internal)
(circle one)
If yes, how often? ______________________________
Type of dressing for central line and does it need to be changed at camp:_____________________________________ _______________________________________________________________________________________________
Any medically prescribed meal plan or dietary restrictions: _________________________________________________
_______________________________________________________________________________________________
Any allergies (food, drug, plants, insects, etc.): __________________________________________________________
Any additional health information: ____________________________________________________________________
_______________________________________________________________________________________________
Signature of Licensed Medical Personnel: ______________________________________________________________
Printed name: ________________________________________ Title: _______________________________________
Address: _________________________________________________________ phone#: ________________________
Date form completed: __________________ By: ____________________________ (initial if done on behalf of physician)
The following consents are for (camper’s name)_______________________________________________________
Authorization for Treatment: The information that I have provided in this application is correct so far as I
know, and the person herein described has permission to engage in all camp activities except as noted.
Furthermore, I hereby give permission to the medical personnel of Camp Bring-It-On, selected by the camp
director, to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes;
and to provide or arrange necessary related transportation for my child. In the event I cannot be reached
in an emergency, I hereby give permission to the physician selected by the camp director or camp medical
personnel to secure and administer treatment, including hospitalization, for the person named above. I also
assume all responsibility of any medical treatment costs (including prescribed medications) that occur while
my child is attending Camp Bring-It-On. This completed form may be photocopied for trips outside of camp.
Signature of parent or guardian:_____________________________________ Date:____________________
Camp Attendance Consent Form & Media Consent
I hereby grant permission for the above named person to attend Camp Bring-It-On. In consideration of
Camp Bring-It-On granting permission to the camper named above to attend camp, the undersigned,
for themselves, their legal representatives, successors and assignees, hereby waive and release any
and all rights, claims, demands and action whatsoever for damages or loss which the undersigned
may have against Camp Bring-It-On programs, its staff, board of directors and volunteers. I also grant
permission for the camper, named above to be transported by a licensed company to any and all camp
activities held off camp premises. I also hereby authorized the interviewing, taking of pictures, motion
pictures/video, and/or television picture of my child, during his/her stay at Camp Bring-It-On, and
consent to the use of any or all such pictures in publication media for Camp Bring-It-On. Camp BringIt-On may list my family among others from my area as utilizing services of Camp Bring-It-On.
Explanation:______________________________________________________________________________
Signature of parent or guardian:_____________________________________ Date:____________________
Mail to: Camp Bring-It-On
Marilee Kontz, Sanford Children’s Camping Coordinator
1305 W. 18th Street, PO Box 5039
Sioux Falls, SD 57117-5039
LIABILITY FORM
Event/Program: __________________________________ Date of Event/Program: ____/_____/______
Participant Name: _______________________________________ Today’s Date: ____/_____/______
Gender: ___________
Date of Birth: _______/_______/__________
Current Age: ______________
Address: ___________________________ City: _________________ State: ______ Zip: __________
Phone Number: _____________________________________ (Circle one: mobile home work )
Parent or Guardian (if minor): ___________________________________________________________
Address: ___________________________ City: _________________ State: ______ Zip: __________
Phone Number: ______________________________________ (Circle one: mobile home work )
IN CASE OF EMERGENCY PLEASE NOTIFY:
Name:___________________________________ Relationship: ________________________________
Address:_________________________________ Phone: _____________________________________
Allergies:
GENERAL INFORMATION:
Comment on the specific nature of the allergy and allergic response : _____________________________________
_____________________________________________________________________________________________
Dietary Instructions:
Please list all food allergies and dietary needs: ________________________________________________________
____________________________________________________________________________________________
_____ Bite-sized food
_____ Pureed food
_____ G-tube
_____ Thicken liquids
Visual:
_____ Blind
_____ Some Sight
_____ Glasses or contacts
_____ N/A
Comments: ___________________________________________________________________________________
Hearing:
_____ Deaf
_____ Partial Hearing
_____ Hearing Aids
_____ N/A
Comments: ___________________________________________________________________________________
Mobility:
_____ Independent (walks/wheels long distances on own)
_____ Uses Aid:
_____ Walks with direct support from another person
Other special restrictions or considerations while at Joy Ranch: _________________________________
_____________________________________________________________________________________________
Continue on back 
PHOTO RELEASE
Joy Ranch and Lutherans Outdoors in South Dakota hereby have my permission to use any photographs
or electronic media taken while at Joy Ranch of me and/or whom I am guardian, to use in any and all
publications, including brochures, articles, website entries, video, billboard, etc without payment or any
other consideration. I understand and agree that these materials will become the property of Joy Ranch
and Lutherans Outdoors in South Dakota and will not be returned.  YES  NO
Signature of parent/guardian/legal representative ____________________ Date ___/___/___
HORSE LIABILITY RELEASE (May not be applicable to all events/programs)
Warning, except for conduct not exempt from liability pursuant to SDCL 42-11-3., under South Dakota
Law, an equine professional is not liable for any injury or death of a participant in horse activities
resulting from the inherent risks of horse activities, pursuant to SDCL 42-11-2.
Signature of parent/guardian/legal representative ____________________ Date ___/___/___
AUTHORIZATION FOR TREATMENT
I hereby give permission to the Joy Ranch health care personnel to provide routine health care and to
administer medications brought to camp; and to the medical personnel selected by the Joy Ranch director
to order X-rays, routine tests, treatment, and necessary transportation for me/or my child. In the event the
contacts above cannot be reached in an emergency, I hereby give permission to the physician selected by
the Joy Ranch director to secure and administer treatment, including hospitalization.  YES  NO
Signature of parent/guardian/legal representative ____________________ Date ___/___/___
Please return to Joy Ranch, , prior to arrival:
Mail: 16633 448th Ave., Florence, SD 57235
Email: ũŽLJƌĂŶĐŚĞǀĞŶƚƐΛůŽƐĚ͘ŽƌŐ
Fax: 605-886-6188
Available Accommodations:
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Hoyer Lift
Adult Changing Table
Wheelchairs
Waterproof Mattress Pad
Bed Rails
012000-00112 Rev. 11/16
If you have any specific concerns or requests
(medical, dietary, behavioral, or accommodation)
you would like to discuss, please contact
Program Director, Jess Larson
(605-886-4622 or [email protected]),
at least one week prior to arrival so that our staff can
prepare for your time at the Joy Ranch.