Camp Application 2016
P.O. Box 428
Woodridge, Ny 12789
[email protected]
646-660-2941
Camper Name: _______________________________________ Child’s Age: ____________
School Currently Attending: __________________________________ Grade:____________
Previous Shiloh Camper:
Yes
No
PARENT/GUARDIAN INFORMATION
Name:_____________________________________ Soc. Sec. #:______________________
Street:_______________________________________ Apt. #:_________________________
City: ____________________________ State: _________ Zip Code:____________________
Home Phone: ________________________ Work Phone: ____________________________
E-mail Address: ________________________ Cell Phone:____________________________
EMERGENCY CONTACT INFORMATION
In the event that the parent/guardian cannot be reached.
1. Name: ______________________________ Relationship:__________________________
Home Phone: ________________________ Work/Cell Phone:______________________
2. Name: ______________________________ Relationship:__________________________
Home Phone: ________________________ Work/Cell Phone:______________________
CHOOSE YOUR SESSION
SESSION
DATE
AGE LEVEL
Session 1
June 26 - July 1
3rd Grade - 12 years old
Session 2
July 3
- July 14
13 - 15 years old
Session 3
July 17 - July 28
11 - 13 years old
Session 4
July 31 - Aug. 5
9 - 11 years old
CHOOSE YOUR PICK-UP LOCATION: Camp Shiloh has the following pick-up
locations. Select the one closest to your place of residence. You will receive a letter of
acceptance with the specific address and time.
Note: There will not be a bus pick up in Brooklyn for any session. We pick up at the Bronx and
Bridgeport locations for all sessions.
Bridgeport, CT . . . . . . . . . . Old Barnum School, 529 Noble Ave. (at Maple St.)
Bronx, New York . . . . . . . . . M.S. 343 and M.S. 224 (Alexander Burger) 345 Brook Ave. (at 141st St.)
T-SHIRT SIZE: S M L XL XXL
(Please circle one - ALL sizes are Adult Sizes)
CAN YOU SWIM?
If yes, What level?
!
!
YES ! NO
Beginner ! Intermediate !
Advance
MEDICAL INFORMATION - You must include a copy of your child’s State Immunization Record with dates the following
information must be present: Diphtheria, Haemonphilus Influenza Type B, Hepatitis B, Measles, Mumps, Poliomyelitis,
Rubella, Tetanus and Varicella (chicken pox). If your child has not had these immunizations, simply state that you have
declined them.
Date of last Physical exam: __________________________
Camper’s current weight ________________________(Lbs.)
Can camper fully participate in the active camp
program? ! Yes ! No
if No, Explain: __________________________
_______________________________________
Does the camper have any of the following
conditions?
Please list your child’s medications, the dose and the time the child
takes the medication:
________________________________________________________
Medication
Dose/Time
________________________________________________________
Medication
Dose/Time
!
Is your child allergic to any medications? ! Yes ! No
Please list: _______________________________________________
________________________________________________________
Asthma
!
Does he/she have inhaler?
!
Frequent ear infections
!
Seizures
!
Heart disease or high blood-pressure
!
Hyperactivity or ADD or ADHD
!
Allergies or Hay Fever
Is your child allergic to any foods? ! Yes ! No
Please list: _______________________________________________
________________________________________________________
!
Other Condition(s) _____________________
_______________________________________
_______________________________________
_______________________________________
If your child is a female, has she menstruated or had her period? ! Yes ! No
if she has not, has she been told about menstruation or her period? ! Yes ! No
Medical Insurance or Medicaid Information Company: ________________________ Policy# ________________________
Group# ________________________ Card holder’s Name: ______________________________
!
Yes, I have included my $10.00 registration fee (personal check or money orders accepted—please do not send cash
through the mail). I am aware that this fee will be used for my child at the Shiloh Camp Store.
This health history above is correct as far as I know. I hereby give permission to Camp Shiloh to be our representative to
consent to any diagnostic procedure or medical care on the minor above mentioned which is deemed advisable by any
licensed physician or surgeon at any accredited health center in the geographical area where an incident requiring medical
needs may happen. Camp Shiloh is released from any liabilities in connection with medical administration except as covered
by camper insurance. This form may be photocopied for use by a health center.
Camp Shiloh, Inc. reserves the right to reject applications and to dismiss a child for any reason it considers in the best interest
of the camp and the other children. Camp Shiloh assumes no responsibility for camper’s personal property.
I have read Shiloh’s camp policy, conditions and restriction in the attached brochure.
I understand and fully agree to abide by Camp Shiloh’s policy.
Parent/Guardian Signature:________________________________________________ Date Signed:_________________
A registered nurse is on staff to administer prescription and nonprescription medication to your child. Please send any prescription
medication in the original containers including the child’s name,
name of the medication and the times the child takes the
medication on the label. Non-prescription or over-the-counter
medication (ex. Tylenol, Advil, Pepto-Bismol, Benadryl, Cough
Syrup, etc.) may be given by the nurse only as needed.
Camp Shiloh Medication Release Form Information
Dear Parent/Guardian:
Attached is a copy of our Medication Release Form.
In order to administer over-the-counter medications to your
child at camp this summer for any reason, we must have a
copy of this form signed by a physician. Medications that
might be administered include Advil for headaches, Pepto
Bismol for nausea, Tylenol for a fever, and Benadryl for an
allergic reaction.
If you would like for your child to be able to receive these
medications or any other medications, please have their
Health Provider fill out and stamp the attached form.
Please bring it to the bus stop when your child departs for
camp.
If you have any questions, please feel free to call our
business office at camp at (646) 660-2941.
Thanks,
Camp Shiloh Staff
Camp Shiloh Medication Release Form
**Please place a check and an order for each over the counter medication that could be
administered to the child while at camp as needed (PRN).
Camper Name: __________________________________________
□
Ibuprofen 200 mg - 400 mg tablets PO q8h PRN for pain - Advil
Order:_________________________________________________
□
Acetaminophen 325mg - 500 mg tablets PO q6h PRN for pain/fever- Tylenol
Order:_________________________________________________
□
Acetaminophen (Children’s Tylenol liquid suspension) 325 mg q6h for pain/fever
Order:_________________________________________________
□
Diphenhydramine HCl 25mg - 50 mg tablets PO q6h PRN for allergies/itching Benadryl
Order:_________________________________________________
□
EpiPen Auto Injector IM as needed for anaphylaxis
Order:_________________________________________________
□
Calcium Carbonate 400mg Chewable tablets PO q4h for upset stomach, diarrhea, nausea,
vomiting- PeptoBismol
Order:_________________________________________________
□
Imodium A-D 2mg -4mg chewable tablets PO q4h PRN for diarrhea
Order:_________________________________________________
□
Claritin 5mg/5ml suspension 1-2 tsp. PO q12h PRN for allergies/itching
Order:_________________________________________________
□
Sudafed PE 5mg-10mg tablets PO q6h PRN for nasal contestation
Order:_________________________________________________
Physician’s Signature:__________________________ Date:________________
Attachment 10
2016 SFSP
INCOME ELIGIBILITY FORM
FOR THE
SUMMER FOOD SERVICE PROGRAM
(For Use by Camps and Closed Enrolled Sites)
Please complete the following form using the instructions below. Sign the form and return it to: [Name of Sponsor]
______________________________________________________________________________________.
If you need help, call [phone number of Sponsor]
Follow these instructions, if your household gets SNAP (Food Stamps) TANF or FDPIR:
Part 1: List participant’s name and a SNAP (Food Stamp), TANF or FDPIR case number.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. A Social Security Number is NOT required.
Part 5: Answer this question if you choose to.
If your household includes a FOSTER CHILD, use one application for the whole household and follow these instructions:
Part 1: Enter the child’s name.
Part 2: Please contact us at [phone number of Sponsor]
Part 3: Complete this part if you are applying for other children in the household and you did not enter a SNAP (Food Stamp), TANF
or FDPIR case number in Part 1.
Part 4: Sign the form. If Part 3 was completed, provide the last four digits of the signing adult’s Social Security Number.
Part 5: Answer this question if you choose to.
ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:
Part 1: List each participant’s name.
Part 2: Skip this part.
Part 3: Follow these instructions to report total household income from last month.
Column A–Name: List the first and last name of each person living in your household, related or not (such as grandparents,
other relatives, or friends who live with you). You must include yourself and all children living with you. Attach another sheet
of paper if you need to.
Column B–Gross income last month and how often it was received. Next to each person’s name, list each type of
income received last month, and how often it was received.
In Box 1, list the gross income each person earned from work. This is not the same as take-home pay. Gross income is
the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can
tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).
In box 2, list the amount each person got last month from welfare, child support, alimony.
In box 3, list Social Security, pensions, and retirement.
In box 4, list ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits,
Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), disability benefits, regular contributions from people
who do not live in your household. Report net income for self-owned business, farm, or rental income. Next to the amount,
write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing
allowance.
Column C–Check if no income: If the person does not have any income, check the box.
Part 4: An adult household member must sign the form and include the last four digits of his or her Social Security Number, or mark
the box if he or she doesn’t have one.
Part 5: Answer this question if you choose to.
Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the
information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the social security number of the adult
household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a SNAP,
Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for your child or
other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a social security number. We will
use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the Program.
Non-discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and
policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from
discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large
print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf,
hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information
may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to
USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your
completed form or letter to USDA by:
(1)
mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2)
fax: (202) 690-7442; or
(3)
email: [email protected].
This institution is an equal opportunity provider.
Attachment 10, Continued
2016 SFSP
Part 1. Children enrolled in Camp or Closed Enrolled Sites.
Names
(First, Middle Initial, Last)
SNAP (Food Stamp), TANF or FDPIR case # (if any). Skip to
Part 4 if you listed a case #.
Part 2. Foster Child
Foster children eligible for free and reduced-price meals regardless of household income. If a foster child lives with you, please contact
[name of Sponsor] at [phone number]. Complete Part 3 if you are applying for other children in your household and you did not enter
a SNAP (Food Stamp), TANF or FDPIR case number in Part 1.
Part 3. Total Household Gross Income—You must tell us how much and how often
B. Gross income and how often it was received
C.
A. Name
Example: $100/monthly $100/twice a month $100/every other week $100/weekly
Check
(List everyone in household,
if NO
1.
Earnings
from
work
2.
Welfare,
child
3.
Social
Security,
including children)
4. All Other Income
income
before deductions
support, alimony
pensions, retirement,
1.
2.
$______/________
$______/_______
$______/_______
$______/_______
$______/________
$______/_______
$______/________
$______/_______
3.
$______/________
$______/_______
$______/________
$______/_______
4.
$______/________
$______/_______
$______/________
$______/_______
5.
$______/________
$______/_______
$______/________
$______/_______
6.
$______/________
$______/_______
$______/________
$______/_______
7.
$______/________
$______/_______
$______/________
$______/_______
8.
$______/________
$______/________
$______/________
$______/________
9.
$______/________
$______/________
$______/________
$______/________
10.
$______/________
$______/________
$______/________
$______/________
11.
$______/________
$______/________
$______/________
$______/________
12.
$______/________
$______/_______
$______/________
$______/_______
Part 4. Signature and Social Security Number (Adult must sign)
An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list the last four digits of his
or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this
page.)
I certify that all information on this form is true and that all income is reported. I understand that this information is being given for the
receipt of Federal funds. I understand that SFSP officials may verify the information. I understand that if I purposely give false
information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Sign here: X______________________________Print name:_____________________________Date: ______________
Address:_______________________________________________________Phone Number:______________________
Last four digits of Social Security Number: __ __ __ __
I do not have a Social Security Number
Part 5. Participant’s ethnic and racial identities (optional)
Mark one ethnic identity:
Mark one or more racial identities:
Asian
American Indian or Alaska Native
Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
Not Hispanic or Latino
Black or African American
Don’t fill out this part. This is for official use only.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12
Total Income: ____________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year
Household size: ________
Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___
Reason: ________________________________________________________________________________________
Determining Official’s Signature: _______________________________________________ Date: ______________
Confirming Official’s Signature: ________________________________________________ Date: ______________
Follow-up Official’s Signature: _________________________________________________ Date:______________
Camp Shiloh Climbing Tower
Release of Liability - Read before signing
In consideration of being allowed to participate in any way in Camp Shiloh, Inc. trainings and/or
workshops, its related activities, I, the undersigned, acknowledge and agree that:
1. The risk of injury from the activities involved in this program is significant, including the potential for
permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce
this risk, the risk of serious injury does exist: and,
2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the
negligence of the releasees or others, and assume full responsibility for my participation, and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If,
however, I observe any unusual significant hazard during my presence or participation, I will remove
myself from participation and bring such to the attention of Camp Shiloh, Inc. immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release,
indemnify, and hold harmless Camp Shiloh, Inc., their officers, officials, agents and/or employees, other
participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises
used for the activity (“Releasees”), with respect to any and all injury, disability , death, or loss or damage
to person or property; whether arising from the negligence of the releasees or otherwise, to the fullest
extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT,
FULLY UNDESTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL
RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY
INDUCEMENT.
X______________________________________
CAMPER / PARTICIPANTS’ NAME
Date:_________________________
FOR PARENT/GUARDIANS OF PARTICIPANTS OF MINORITY AGE
(under age 18 at time of registration)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and
agree to his/her release as provided above of all the Releasees, and, for myself, me heirs, assigns, and next
of kin, I release and agree to indemnify and hold harmless the releasees from any and all liabilities
incident to my minor child’s involvement or participation in these programs as provided above, even if
arising from the negligence of the releasees, to the fullest extent permitted by law,
X________________________________________________
PARENT/GUARDIAN SIGNATURE
Date:________________________
__________________________________________________________________
EMERGENCY PHONE NUMBER(S)
Photo/Video Release Form
AUTHORIZATION TO USE PHOTOGRAPHS AND/OR AUDIO-VISUAL
I, _____________________________, hereby authorize and consent to the use
of my visual image of my child by Camp Shiloh and Shiloh Ministries for
appropriate purposes, including but not limited to: still photography,
videotape, electronic and print publications, and websites. I give this consent
with no claim for payment.
Signature:_____________________________
Date:________________
Phone:________________________________
For a child under 18 years of age, complete the form below.
I, _______________________, Parent/Guardian of _____________________
hereby authorize and consent to the use of his/her visual image by Camp
Shiloh and Shiloh Ministries for appropriate purposes, including but not
limited to: still photography, videotape, electronic and print publications and
websites. I give this consent with no claim for payment.
Signature______________________________
Date________________
Phone_________________________________
Por la presente autorizo y consentimiento para el uso de la imagen visual de mi
hijo por Camp Shiloh y Shiloh Ministries para fines apropiados, incluyendo,
pero no limitado a: fotografía fija, video, publicaciones electrónicas e impresas
y sitios web. Le doy este consentimiento sin pretensión de pago.
Firma/Signature:___________________________
Fecha:___________
Número de teléfono:_________________________
Para un niño menor de 18 años de edad, complete el siguiente formulario.