1. 2008 Outrigger Island RETREAT
  2. REGISTRATION & MEDICAL INFORMATION FORM
      1. (Please complete all four pages of this form.)
      2. ADDITIONAL HEALTH INFORMATION
      3. MEDICATIONS
      4. DAILY LIVING
      5. OTHER INFORMATION
      6. POLICIES & PROCEDURES
      7. BEFORE YOU SEND IN YOUR REGISTRATION…
  3. COUNSELOR CONTRACT
      1. Form must be returned no later than September 12.
For Camp Use:

Cabin Assigned ____

 
2008 Outrigger Island RETREAT

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REGISTRATION & MEDICAL INFORMATION FORM
 
Note to church contact person: Please duplicate this form for each camper and counselor.
Mail or fax to: Preschool and Children’s Ministries, 3800 N May Ave. Oklahoma City, OK 73112
Fax: 405-516-4923 so that information is received in our office no later than September 12.

               

Name________________________________________________________  Birth Date _____________ Age ________  
Last             First              
 
Parent or Guardian _______________________________________________ Home Phone (_____) _______________
                                                   Area   Number
Home Address ______________________________________________________________________________________
          Street & number City State Zip Code
  Email Address_______________________________________________________________________________________
 
Parent/Guardian Work Phone(s) (_____)______________________ (_____)__________________________________
                                          
Counselor’s Name____________________________________ Phone (____)__________________________________
 

List one other person who would know where parents can be reached or could get word to them in case of emergency:
 
Name ________________________________________________________________- (_____) ____________________
Area    Number
 Relationship to camper____________________________________________________________________________
 
Do you have health insurance coverage?     o Yes     o No
 
If “Yes”, give name of carrier ____________________________________________  Policy # ______________________
 
Doctor’s name ____________________________________________________________  (_____) ___________________
 

 
Please check tee-shirt size. Adult: Small____ Medium_____ Large_____ x-large____ xx-large_____ xxx-large_____

                         
HEALTH HISTORY: (Check Yes or No. If “Yes”, give approximate date, or most recent date.)
 
 
        Yes    No Date
Ear Infection     o     o ________
Rheumatic Fever   o     o ________
Convulsions     o     o ________
Diabetes       o     o ________
Irregular Behavior   o     o ________
 
ALLERGIES    Yes No Date
Hay Fever       o     o ________
Poison Ivy, etc     o     o ________
Insect Stings     o     o ________
Penicillin       o     o ________
Other Drugs     o     o ________
 
DISEASES       Yes No Date
Chicken Pox     o     o ________
Measles       o     o ________
German Measles   o     o ________
Mumps       o     o ________
Asthma       o      o ________
 
Special Needs     o     o ________                       Heart Concerns o        o ________
Fainting o     o ________
Other diseases or details of above ______________________________________________________________________
 
__________________________________________________________________________________________________
 
Chronic or recurring illness ____________________________________________________________________________
 
Operations or serious injuries (include dates) ______________________________________________________________
 
IMPORTANT: Please notify the camp if this camper is exposed to any communicable disease during the three weeks prior to camp attendance.
Suggestions from guardian ____________________________________________________________________________
 



(Please complete all four pages of this form.)
 
 



ADDITIONAL HEALTH INFORMATION
 

Most Recent Tetanus Booster ____________________
                 (Please give date.)
 

 
Special Diet _____________________________________________________________________________________

Does camper have food allergies or other dietary restrictions or requirements that need to be monitored by counselor or staff? o Yes   o   No
If yes, please list:________________________________________________________________________________
 
If camper is on a weight loss program or has diabetes, please indicate what sort of snacks, desserts, etc. are allowed on the diet: ____________________________________________________________________________________
 
______________________________________________________________________________________________
 

    
Strenuous activity?________________________________________________________________________________
Are any specific activities to be restricted? ____________________________________________________________
Other comments__________________________________________________________________________________


  
MEDICATIONS
MEDICATIONS BROUGHT TO CAMP MUST BE IN ORIGINAL CONTAINER WITH INSTRUCTIONS ATTACHED.
Please note that this includes vitamins and any over-the-counter medications.

Special medicine (give name of medicine) _____________________________________ Is parent sending it? ______
 

  
Permission is given for my camper to receive over the counter medication YES _____ NO ______


  
DAILY LIVING
Degree of disability: Check one
o Mild: Performs all activities of daily living and self care with minimal or no assistance.
o Moderate: Performs all activities of daily living, but at slow speed and with some assistance.
o High: Unable to perform all activities of daily living. Requires constant assistance.
 
Briefly describe camper’s communication skills: _______________________________________________________

Does the camper have any physical limitations? o Yes   o No   o Occasionally o Constantly
 

  
Assistance: Please indicate with I-Independent    V-Verbal prompting    F-Full Assistance
Dressing ___      Deodorant ___      Brushing Teeth ___      Using Toilet ___
Brushing Hair ___    Showering___      Shaving ___        Washing Hair ___      
Menstrual Hygiene ___  Incontinence Supplies ___


 
OTHER INFORMATION
Has camper attended camp before? _____  If so, where? _____________________________________________

 
Name of school/group home: _________________________________________  Phone: ____________________
 
 
 



POLICIES & PROCEDURES
 

 
· Admission—This retreat is open to any trainable, educable mentally handicapped persons 18 years or older. Campers must have no life-threatening condition. Any contagious disease must be listed on registration form. A responsible adult, designated as a counselor must accompany each camper. One counselor may accompany up to three campers of the same gender. Campers requiring assistance with mobility, behavior management, or skills, must provide one-on-one staffing during the duration of the retreat.
· Counselor Contract—Each counselor, and his supervisor, must sign a contract that defines the responsibilities and duties of the counselor. If the contract is broken, the counselor’s supervisor will be contacted and the counselor and his/her camper(s) will be required to leave the camp. If a parent is serving as counselor, his or her signature is sufficient.
· Medications—The camp nurse will administer all medications (over-the-counter and prescription.) All medications must be in original container. Medication will be stored in the nurse’s station.
· Universal Precautions—Staff and counselors will use universal precautions (gloves, bleach solution) when cleaning any bodily fluids.
· Camper, Counselor & Staff Identification—All campers, counselors and staff will wear identification badges at all times outside the cabins. Each attendee is also required to wear appropriate camping clothing (t-shirts, jeans or long shorts, no short shorts, halter top, mini skirt, etc).
· Falls Creek – The camp is a smoke free campground and any attendee that feels they must smoke may do so outside the campground front gate. Before going or taking a camper outside the front gate to smoke, leadership must be notified.



BEFORE YOU SEND IN YOUR REGISTRATION…
 

Registration forms are processed on a first come first served basis. Accommodations are limited.
 
When mailing in registration all forms must be complete, correct, and include payment in order to be processed. 
 
Please include:
 
  o  All pages of camper registration form. If a question does not apply, please answer with N/A.
  o Counselor registration form. (Back of this page)
    o Signed counselor contract. See policy above.
    o Background check (on counselor) completed by camper’s church. If no recent background check is available
from church, contact our office (405-942-3000, ext. 4648) for a form and return it with registration, or    
download a form at www.bgco.org . Click on “Resources” at top of page, then “Preschool & Children,” then “Forms.”
    o $65.00 camper registration fee, check payable to BGCO.
    o $65.00 counselor registration fee, check payable to BGCO.  
AUTHORIZATION OF PARENT OR GUARDIAN
 
This health history and other information are correct as far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for the camper named above.
 
Signature of parent or guardian__________________________________________Date_______________
 
PHOTO RELEASE
This year at the retreat we will take various pictures for promotional purposes. Please check below to indicate your preferences.
 
c YES, I give permission for my camper’s pictures to be taken during the retreat.
 
c NO, I do not want my camper to have his/her picture taken during the retreat.
 

 
 

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COUNSELOR CONTRACT
 
No counselor will be allowed to stay at the retreat if this form is not filled out
and signed by the counselor and his or her supervisor.
 

 
I, ________________________, agree to the following camp rules and procedures set forth by Perfect Wings Retreat. Should any rule or procedure be broken the camper(s) I am caring for and I will be asked to leave the Falls Creek campus by the Perfect Wings Retreat leadership.
 

        
1. Counselor will not physically leave the campus without the prior approval of the retreat leadership.
2. Counselor will be with his/her camper(s) during meal times, recreation, rest/free time, and is responsible for his/her camper(s) overnight. Counselor may be required to assist in classroom if his/her camper requires assistance.
3. Counselor will attend to any necessary care the camper(s)may need in the areas of personal hygiene, feeding, and mobility.
4. Counselor will inform Perfect Wings Retreat staff of any contagious diseases his/her camper may have.
5. Counselor will assist the camp nurse in administering the camper’s over-the-counter and prescribed medication.
6. Counselor may attend optional classes designed for him/her by the Perfect Wings Retreat staff. If not attending class, counselor must inform Perfect Wings Retreat staff of his/her location.
7. Counselor must attend a mandatory orientation meeting held the first night of Perfect Wings Retreat.
8. Counselor must be present at all camper events as designated in the retreat handbook (will receive upon check-in at camp).
9. Counselor has obtained a current background check by his/her church or organization:

o Yes. Verification provided below.
o No. Please send the required form to the address below.



Form must be returned no later than September 12.
 
 
 
_____________________________    _________________
       Counselor’s signature            Date
 
 ____________________________________________________________________________
 Street address, city, state & zip (Please print neatly.)
 
I, _____________________________ (pastor or supervisor’s signature) verify that a current background check has been completed on the above-named individual by our church or organization. _________________________________ (Printed name of pastor or supervisor)

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