Fossil Rim Wildlife Center
Ph: 254-897-2960, Fax Number: 254-898-4091
PLEASE FILL OUT A FORM FOR EACH CHILD. CHILD INFORMATION
LAST NAME___________________FIRST NAME__________________ AGE ____ DOB _______M/F___ PARENT INFORMATION LAST NAME _____________________________ FIRST NAME ______________________________ Relationship to Child _______________________ Primary Contact Number _____________________ Applying for Scholarship ___YES ____NO Siblings attending ____YES ____NO Other Relatives/Friends Attending _____Yes _____No Name(s):____________________________________________________________________________ Going Native, Summer Camp 2011 “Wild Matters” (July 22-24) Discounts for Siblings: First child pays full price. Siblings receive a 10% discount. Parents: Do you want to come to camp, too? Sign up to be a camp parent to receive 40% off tuition for your child, and enjoy all camp activities! You can bunk in our rustic cabins, enjoy the guided tour, practice your archery, create a nature journal, relax under the starts, and more! Cabin parents must submit to a background check before attending a camp.
Page 1 of 7 Payment Information:
Credit Card Payments: Billing will occur approximately 14 days prior to camp. Check Payments: Payment by check is due no later than 21 days prior to the event or the camp reservation will be cancelled. Check(s) will be deposited upon receipt no sooner than 21 days prior to camp date, and no later than 14 days prior to camp date. DONATIONS – Fossil Rim Wolf Ridge Summer Camp operates on the premise that our programs, facilities, and staff are an effective way to teach children how to be stewards of our planet. If you share this vision, then please consider donating of your time, talents, gifts, and service. In addition, Fossil Rim Wildlife Center invites organizations to partner with youth who wish to attend camp and who face hardship in paying the full tuition. Yes! I believe in teaching children the importance in being good stewards of our Earth and its inhabitants. I want to respond with a gift of: $25______ $50______ $75 ______ $100 ______ other $________ II would like to donate a full scholarship for a child to attend camp in the amount of: $75 Day Camp______
Sponsorship of a family or group camp $____________ _____ PLEASE BILL MY CREDIT CARD ON FILE FOR THE ABOVE DONATION AMOUNT. _____PLEASE CONTACT ME FOR DONATION INFORMATION. Scholarship Information: Scholarships will be awarded based on financial need and/or merit. If you would like to be considered for a scholarship, please complete the following section:
a. Below $10,000 b. $10,000 to $18,000 c. $18,000 to $25,000 d. $25,000 to $32,000 e. $32,000 to $40,000 f. Above $40,000 Number of adults _____ children _____ in household.
Why do you need a scholarship? _________________________________________________________________________________ _________________________________________________________________________________
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Dates will attend camp: from ___________________to________________
Camper Name: _________________________________________________________________________
Developed and reviewed by: American Camp Association,
Birth Date: ____________ Age on arrival at camp: ________
American Academy of Pediatrics Council on School Health, &To Parent(s)/Guardian(s): Please follow the instructions below. ATTN: Education Department Attach additional needed information. Fossil Rim Wildlife Center 2155 County Road 2008 1)Complete all pages of this form and make a copy. Glen Rose, TX 76043 2)Mail this signed form to the address below by (date)
Camper Home Address: _________________________________________________________________________________________________________________________
Parent/guardian with legal custody to be contacted in case of illness or injury:
Name: ____________________________ to Camper: ________________ Preferred Phones: (______) ________________ (______)_________________
Email: ___________________________________________
Home Address: ______________________________________________________________________________________________________________________________ (If different from above) Street Address
Second parent/guardian or other emergency contact:
Name: ____________________________ to Camper: ________________ Preferred Phones: (______) ________________ (______)_________________
Email: ___________________________________________
Additional contact in event parent(s)/guardian(s) can not be reached:
Name: ____________________________ to Camper: ________________ Preferred Phones: (______) ________________ (______)_________________
Email: ___________________________________________
Allergies: □ No known allergies □ This camper is allergic to:
□ Food □ Medicine □ The environment (insect stings, hay fever, etc.) □ Other
(Please describe below what the camper is allergic to and the reaction seen.)
_________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________
Diet, Nutrition: □ This camper eats a regular diet. □ This camper eats a regular vegetarian diet. □ This camper has special food needs. (Please describe below.)
_________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________
Camp Activities Restrictions: □ I feel the camper can participate in camp activities without restrictions.
□ I feel the camper can participate in camp activities with the following restrictions or adaptations. (Please describe below.)
_________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________
Medical Insurance Information:
This camper is covered by family medical/hospital insurance: □ Yes □ No
*Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company______________________________ Policy Number___________________________
Subscriber_____________________________________ Insurance Company Phone Number (______) ___________________
Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician and/or paramedics selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician and/or paramedics to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
_____ INITIAL HERE (Parent / Guardian)
If for religious or other reasons you cannot initial this, contact the camp manager at (254)897-2960 Copyright Page 3 of 7
Camper Name: _______________________________________________________
Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses
The following non-prescription medications may be stocked in the Infirmary and are used on an as needed basis to manage illness and injury.
Cross out the medications that the camper (should not) be given: ications that the camper (should not) be given:
Phenylephrine decongestant (Sudafed PE)
Diphenhydramine antihistamine/allergy medicine (Benadryl)
Dextromethorphan cough syrup (Robitussin DM)
Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)
Medication: □ This camper will not take any daily medications while attending camp.
□ This camper will take the following daily medication(s) while at camp:
"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. We require original pharmacy containers with labels which show the camper’s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp. (Medication cannot be shared between siblings. They must have their prescription.) Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization forms
from health-care providers or state or local government are an acceptable alternative; please attach to this form.
Month/Year Month/Year Month/Year Month/Year
If your camper has not been fully immunized, please acknowledge your understanding of the following statement by signing below: I understand and accept the risks to my child from not being fully immunized. _____ INITIAL HERE (Parent / Guardian)
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Camper Name: _______________________________________________________
Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses General Health History:Check "Yes" or "No" for each statement. Explain “Yes” answers below.
1. Ever been hospitalized? …………………………. □ Yes □ No 11. Had fainting or dizziness? . □ Yes □ No
2. Ever had surgery? . …………. □ Yes □ No
12. Passed out/had chest pain during exercise? ….……………. ………… □ Yes □ No
3. Have recurrent/chronic illnesses? .……….… □ Yes □ No 13. Had mononucleosis ("mono") during the past 12 months?. □ Yes □ No
4. Had a recent infectious disease? . …………. □ Yes □ No
14. If female, have problems with periods/menstruation?.……. …………. □ Yes □ No
5. Had a recent injury? . …………. □ Yes □ No
15. Have problems with falling asleep/sleepwalking? . □ Yes □ No
6. Had asthma/wheezing/shortness of breath?. □ Yes □ No
16. Ever had back/joint problems?…….……….……………. □ Yes □ No
7. Have diabetes? . …………. □ Yes □ No
17. Have a history of bedwetting?………………….……………. □ Yes □ No
18. Have problems with diarrhea/constipation?……………………………… □ Yes □ No
9. Had headaches? …………………………………. □ Yes □ No
19. Have any skin problems?……………………. □ Yes □ No
10. Wear glasses, contacts, or protective eyewear? □ Yes
No 20. Traveled outside the country in the past 9 months?. □ Yes □ No
Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Mental, Emotional, and Social Health:Check "Yes" or "No" for each statement.
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ……………………………… □ Yes
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……. □ Yes □ No
3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….…………………………………. □ Yes □ No
4. Had a significant life event that continues to affect the camper’s life?. □ Yes □ No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)
Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information. Answering yesto these questions will
not disqualify your child from attending. _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________
Health-Care Providers:
Name of camper’s primary doctor(s): ____________________________________________________ Phone: (________) ________________________
Name of dentist(s):___________________________________________________________________ Phone: (________) ________________________
Name of orthodontist(s):_______________________________________________________________ Phone: (________) ________________________
What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed. _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________
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Camper Name: _______________________________________________________
Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses A. Medical Consent, Liability Release, and Waiver:
I, the parent / guardian of the child mentioned in page 1 of this document, give my permission for Fossil Rim Wildlife Center Staff permission to take the necessary steps to ensure the health and safety of my child; including but not limited to the administration of first aid, CPR, and / or transportation of the said minor to the nearest hospital or clinic for medical treatment. _____ INITIAL HERE (Parent / Guardian)
I, the parent / guardian of the child mentioned in page 1 of this document, have indicated on page 2 which over-the-counter medications my child can and cannot take. I am giving Fossil Rim’s staff permission to administer these medications according to my selections on an as-needed basis. _____ INITIAL HERE (Parent / Guardian)
B. Social Network Disclaimer
I agree to refrain from negative, derogatory, slanderous, or reputation damaging practices, aimed towards the detriment of Fossil Rim Wildlife Center, due to any social networking activity including but not limited to blogging, Facebook, MySpace, and/or Twitter. _____ INITIAL HERE (Parent / Guardian) C. Photo / Video Release
By initialing, I understand that at this event or related activities, I may be photographed. I hereby consent to allow my photo, video, or film likeness to be used for any legitimate purpose, including but not limited to marketing, advertising, and/or social networking by the event holders, producers, sponsors, organizers and assigns. The photos will not be used for any purpose other than the stated purpose. Not all photos will be used; only those deemed most advantageous for the purpose intended and that most accurately depict the subject matter. _____ INITIAL HERE (Parent / Guardian)
D. Camp Information
Fossil Rim Wildlife Center’s overnight and day camps are designed to provide an opportunity to learn about our conservation efforts. Because a major part of the camp experience will involve interacting with all aspects of nature, including animals, we ask that campers behave in a responsible and cooperative manner at all times. We are confident that each participant will have an educational and fulfilling experience; however, those who find it difficult to be kind and respectful will be asked to sit out, and if necessary, removed from camp. No refund will be provided if a participant is removed from camp due to inappropriate behavior. _____ INITIAL HERE (Parent / Guardian)
I acknowledge that camp is an outdoor activity in which my child will participate at their own risk. I acknowledge that they will be walking and riding in vehicles on rough uneven terrain through wildlife inhabited wilderness. I understand that they will need to follow all of Fossil Rim Wildlife Center rules and regulations for all activities and understand that I am fully responsible for my child’s actions. I release and forever discharge Fossil Rim Wildlife Center, its employees, agents, members, sponsors, promoters, and affiliates from any and all liability claim, cost, or expense, and waive any such claims against any such person or organization, arising directly from any such activity in which my child may participate during camp. Further, I agree to participate in AMA approved mediation regarding any disputes arising from this activity. My child currently has no physical or mental condition that would impair their capability for full participation as intended and expected. _____ INITIAL HERE (Parent / Guardian) I, as a parent / guardian of the participant mentioned in page 1 of this document, represent to Fossil Rim Wildlife Center that the facts herein concerning my child or ward are true. I hereby give my permission for my child or ward to participate in camp activities and events. Further, in consideration granting such license, agree, individually and on the behalf of my child or ward, to the terms of the above agreement and release of liability. _____ INITIAL HERE (Parent / Guardian) E. General Accident Waiver and Release of Liability I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING AND/OR VOLUNTEERING IN THIS ACTIVITY OR EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by Fossil Rim Wildlife Center or High Hope Ranch, or because of their possible liability without fault. I acknowledge that this Accident Waiver and Release of Liability document will be used by the event holders, sponsors, and organizers of the activity or event in which I or my child might participate, and that it will govern my actions and responsibilities at the said activity or event. I WAIVE, RELEASE, AND DISCHARGE FROM ANY AND ALL LIABILITY, including but not limited to , liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event. THE FOLLOWING ENTITIES OR PERSONS: Earth Promise dba Fossil Rim Wildlife Center, High Hope Ranch, and/or their directors, officers, employees, volunteers, representatives, and agents, the activity or event holders, activity or event sponsors, and/or activity or event volunteers. _____ INITIAL HERE (Parent / Guardian) I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND THE CONTENT THEREIN. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT THAT I AM SIGNING OF MY OWN FREE WILL. THIS CONTRACT STANDS ALONE AND IS NOT CONTINGENT UPON ANY OTHER SPOKEN OR WRITTEN INSTRUMENT. Print Participant’s name: ___________________________________________
Participant’s Signature: ____________________________________________
*Parent/Guardian must sign if participant is under age 18 Parent/Guardian Signature: ________________________________________
Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records
Copyright 2008 by American Camping Association, Inc.
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Camper Name: _______________________________________________________
Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Individual Health Record (For Camp Use Only) Initial Screening: Date/Time:_________ Initials: ____________
Screening has been conducted according to camp protocol and significant findings noted as follows:
A. Any signs/symptoms of illness or injury upon arrival?. □ No □ Yes as noted below
B. History of exposure to communicable disease?. □ No □ Yes as noted below
C. Additions or corrections to information on this health history?. □ No □ Yes as noted below
D. Medication turned in to health-care staff?. □ No □ Yes as noted below
E. Any signs/symptoms of head lice?. □ No □ Yes as noted below
Provider notes: (date/time/initial all entries) ___________________________________________________________________
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Exit Note: Check one of the following:
□ Left camp this day with no reported illness or injury symptoms.
□ Left camp this day with the following problem/concern:
____________________________________________________________________________________________________________________
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____________________________________________________________________________________________________________________ This person was told about the problem and instructed about follow-up as noted above: (Name)______________________________ Date/Time: ___________ Initials: __________ Copyright
Inc. Page 7 of 7
Synopsis: Assessing The Effectiveness Of Various Treatment Methods For Removing Endocrine Disrupting Compounds From Domestic Wastewater Problem and Research Objectives In recent years, it has been determined that various synthetic and natural compounds can mimic, or interfere with the action of natural hormones and disrupt the endocrine systems of humans and wildlife. These substances, coll