Date of Application

MM

DD

YYYY

Child-Size T-shirt

S

M

L

XL

Adult-Size T-shirts

S

M

L

XL

Camper's Name

First Name

Last Name

Sex

Female

Male

Date of Birth

MM

DD

YYYY

Child’s Ethnicity/Race:

White

Black/African-American

Hispanic

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Other Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Other Phone

(###)

###

####

Name

First Name

Last Name

Home Phone Number

(###)

###

####

Other Phone Number

(###)

###

####

Name

First Name

Last Name

Please check if your child has displayed any of the following behaviors:

Aggressiveness

Difficulty with peers

Difficulty with authority

Bed-wetting

Tearfulness/Sadness

Sleep difficulties

Hyperactivity

Eating/Food Issues

Does this child take behavior related medication?

Yes

No

To the best of your knowledge, has this child used regularly or experimented with any of the following?

Tobacco

Alcohol

Marijuana

Prescription Drugs (other than as directed)

Other (please explain)

What is this child’s HIV status?

Positive

Negative

Are they aware of their status?

Yes

No

Has this child ever stayed away from home for more than one day/night?

Yes

No

Signature *

First Name

Last Name

Parent or Guardian Signature *

First Name

Last Name

Date

MM

DD

YYYY

I understand that, subject to the terms of this agreement, Camp Starlight will maintain the confidentiality of information about me/my child.

It is the goal of Camp Starlight to use confidential camper information to the minimum extent necessary to provide its campers with effective services.

I understand and consent to Camp Starlight sharing confidential information about me/my child within the agency (including staff, independent contractors and camp volunteers) to the minimum extent necessary to provide me/my child with the services I request or receive. I also understand that my/my child’s information will be shared to comply with program requirements of its funding sources, including governmental and nongovernmental entities.

I understand that, except as set forth in this agreement, information will not be released to anyone outside the agency without my permission, except that, under certain circumstances, release of information may be allowed, authorized or required by law, including:

• Information may be shared with medical/health professionals outside of Camp Starlight if treatment has been requested and information is needed to facilitate that treatment
• Information may be shared with physicians and other health care providers to the extent necessary to facilitate emergency medical diagnosis and/or treatment
• Information may be released if necessary to assist in the investigation of a crime
• Information may be released if necessary to prevent the commission of a crime or when information indicates a clear and immediate danger to the client or others
• Any information relating to suspected child abuse, suspected abuse of elderly persons, or suspected abuse of nursing home patients may be subject to mandatory reporting requirements, and such information may be shared with law enforcement officers.

I understand that Camp Starlight is not identified on the return address of that mail. However, I understand that, if I am also a Camp Starlight volunteer or financial donor, I will receive mail with Camp Starlight identified as the sender, even if I check the “do not” box indicating I do not wish to receive client mail.

I DO wish to receive mail from Camp Starlight.

Yes

No

Signature *

First Name

Last Name

1) RELEASE OF LIABILITY. In consideration for allowing my child to participate in the Camp Starlight program I hereby release, waive and discharge Camp Starlight and all their directors, officers, agents, representatives, volunteers, employees and assigns(hereinafter (“Camp Starlight”) from all liability known and unknown, now or later arising, to my child, myself, my spouse, or the legal representatives, heirs, and assigns of any of us, for any and all loss or damage, and any claims or damages resulting there from, on account of any injury to my child and/or my child’s property and/or my property, including any injury resulting in the death of my child, whether caused by the active or passive negligence of Camp Starlight, connected to my child’s participation in camp program activities, including but not limited to any transportation to or from the camp, but excluding only gross negligence or wanton or willful misconduct. Knowing the risks associated with camp activities generally, and specifically the risks associated with transmission of HIV/AIDS, I hereby agree to assume those risks and to release and hold Camp Starlight harmless from all such risks.

2. AGREE TO ASSUME RISKS. I recognize that the Camp Starlight program is a camp for children affected by or infected with HIV/AIDS. I hereby give permission for my child to attend Camp Starlight whether or not she/he is infected with HIV/AIDS. I understand that Camp Starlight personnel will make a good faith effort to maintain the confidentiality of my child’s (and/or any family member’s) HIV/AIDS status. If my child is not aware that he/she (and/or a family member) is infected with HIV/AIDS, I assume all risks in connection with my child learning that he/she (and/or family member) is infected with HIV/AIDS. I waive, release and discharge Camp Starlight from any and all liability resulting from such disclosure to my child under all circumstances, including but not limited to disclosure due to the active or passive negligence by Camp Starlight or otherwise.

3) AGREEMENT TO INDEMINFY. I agree to indemnify, defend and hold Camp Starlight harmless from any and all actions, claims, judgments, losses, liabilities, damages or cost (including attorney’s fees) I, my spouse, or my child, or the legal representatives, heirs or assigns of any of us may incur due to my child’s participation in camp program activities, whether caused by the active or passive negligence of Camp Starlight or otherwise, but excluding only gross negligence or wanton or willful misconduct.

4) SEVERABILITY. I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the law of the State of Oregon in accordance with its terms. If any portion of this release, waiver and indemnity agreement is held invalid, it is agreed that the balance shall continue in full legal force and effect.

5) AUTHORIZATION FOR TREATMENT. I hereby authorize Camp Starlight personnel or trained medical personnel, as appropriate, to administer to my child any medical treatment deemed necessary in the event of any injury my child sustains while at Camp Starlight or being transported to or from the camp location. I have appropriate insurance or, in its absence, agree to pay all costs of rescue and/or medical services as may be incurred on my child’s behalf. In the event that I leave my place of residence during the camp session, I will advise the Camp Starlight camp administration where I may be contacted in the event of an emergency.

6) AGREEMENT BINDING ON HEIRS. This agreement shall bind my heirs, personal representatives, assignees, and all members of my family, including my child, to the terms to which I have agreed.

7) GENERAL INTENT. My intent in signing this form is to agree not to sue and to release Camp Starlight for injury to my child, my family, or myself or the legal representatives, heirs or assigns of any of us resulting from Camp Starlight’s negligence. I agree to indemnify Camp Starlight for lawsuits brought by me, my spouse or child, or the legal representatives, heirs or assigns of any of us that are based on conduct determined to be simple negligence.

I have read and understand the conditions of this agreement.

Camper Name

First Name

Last Name

Parent/Guardian Signature

First Name

Last Name

Date

MM

DD

YYYY

Camp Starlight will be an exciting week for campers, volunteers and camp program staff! Camp Starlight will photograph and videotape Camp Starlight campers to share with campers, staff, and to be used for fundraising purposes. We intend to take a group camp photo as well. We believe that it is appropriate for campers to have photos of their camp experience. It can also prove helpful for Camp Starlight to use photos of camp activities to raise funds to enable Camp Starlight and the Camp Starlight program to continue their important mission.

I grant permission for my child to participate in the Camp Starlight group photo, general photos, and video of campers to be shared with campers, volunteers, and staff, and to be used by Camp Starlight for fundraising purposes. I further grant Camp Starlight, and its officers, directors, employees, contractors and volunteers, the unrestricted right to take photographs and video of the camper identified below (“Camper”) or in which the Camper may be included (the “Photos”), and to use the Photos for illustration, promotion, advertising, fundraising, or any other purpose in connection with Camp Starlight and its business activities without financial compensation to the Camper, including, but not limited to, using the Photos in calendars, brochures, newsletters and the Camp Starlight website.

I release and agree to hold harmless and indemnify Camp Starlight, and its officers, directors, employees, volunteers and contractors, from any claims, losses, or liability based on or in any way related to the use of the Photos in any manner.

I understand that Camp Starlight does not monitor camera use by individual campers or volunteers, and hereby release and agree to hold harmless and indemnify Camp Starlight, and its officers, directors, employees, volunteers and contractors, from any claims, losses, or liability based on or in any way related to an individual camper’s or volunteer’s use or publication of photographs or video taken by the individual camper or volunteer of or including the Camper.

Check here if you grant permission

I decline permission for my child to participate in the Camp Starlight group photo, general photos, and video of campers to be shared with campers, volunteers, and staff. Although I have declined permission for the Camper to be photographed by Camp Starlight staff, I understand that Camp Starlight does not monitor camera use by individual campers or volunteers, and hereby release, and agree to hold harmless and indemnify Camp Starlight, and its officers, directors, employees, volunteers and contractors, from any claims, losses, or liability based on or related in any way to an individual camper’s or volunteer’s use or publication of photographs or video taken by the individual camper or volunteer of or including the Camper.

Click here if you decline permission

I have read, understood, and completed the above Photo Release form for the Camp Starlight.

Camper Name

First Name

Last Name

Parent/Guardian Signature

First Name

Last Name

Date

MM

DD

YYYY

The following information must be provided by the participant’s Parent/Guardian. The intent of this form is to provide camp health care personnel the background to provide appropriate care. Any changes to this form should be provided to Camp Starlight’s health personnel upon the participant’s arrival at camp. Please provide complete information so that the camp is fully aware of your child’s needs. Thank you.

Camper Name *

First Name

Last Name

Contact Phone number

(###)

###

####

Phone

(###)

###

####

Effective through September 2013?

Yes

No

Physician Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Phone

(###)

###

####

This health history is correct and complete as far as I know. The person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the medical personnel at Camp Starlight to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child.

In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp.

Signature of Parent/Guardian

First Name

Last Name

Date

MM

DD

YYYY

ALLERGIES (list all known)

Allergies (include insect stings, hay fever, asthma, animals, etc.)

DESCRIPTION OF REACTION AND HOW IT IS MANAGED

GENERAL QUESTIONS (explain “yes” answers below)

1. Had any recent medical condition (e.g. illness, injury)?

Yes

No

2. Ever been hospitalized?

Yes

No

3. Ever had surgery?

Yes

No

4. Have frequent headaches?

Yes

No

5. Ever had a head injury or been knocked unconscious?

Yes

No

6. Wear glasses, contacts or protective eyewear?

Yes

No

7. Ever had frequent ear infections?

Yes

No

8. Ever had chest pains, been dizzy, or passed out during or after exercise?

Yes

No

9. Ever had seizures or epilepsy?

Yes

No

10. Ever had high blood pressure?

Yes

No

11. Ever been diagnosed with a heart murmur?

Yes

No

12. Ever had back problems?

Yes

No

13. Ever had problems with joints (e.g. knees, ankles)?

Yes

No

14. Bringing an orthodontic appliance to camp?

Yes

No

15. Have any skin problems (e.g. itching, rash, acne)?

Yes

No

16. Have diabetes?

Yes

No

17. Have asthma?

Yes

No

18. Had problems with diarrhea/constipation?

Yes

No

19. Have problems with sleepwalking or bed-wetting?

Yes

No

20. Ever had emotional difficulties for which professional help was sought?

Yes

No

Please explain any “yes” answers, noting the number of the question.