Camp Amigo 2018July 15-21, 2018

Natahala Outdoor Center, Bryson City North CarolinaChild (Camper) Application

NAME: ___________________________________________ SEX: MALE______ FEMALE_______ AGE: _____

ADDRESS: _______________________________________ DATE OF BIRTH: ____________________________

__________________________________________________ SOCIAL SECURITY #: ________________________

PHONE: ___________________________________________ EMAIL: _____________________________________

MOTHER’S NAME: ________________________________ T SHIRT SIZE (ADULT): S___ M___L___XL___

PHONE: ____________________________________________ XXL____

FATHER’S NAME: __________________________________

PHONE: _____________________________________________

MEDICAL/ INSURANCE INFORMATION

HEALTH INSURANCE COMPANY: ______________________________________________________________

POLICY #:___________________________________________ EXPIRATION: ____________________________

MEDICARE/ MEDICAID #: _____________________________________________________________________

DOCTOR’S NAME: _________________________________________________ PHONE: ___________________

HEALTH CONDITIONS: _________________________________________________________________________

ALLERGIES: ____________________________________________________________________________________

EMERGENCY CONTACT INFORMATION

WE MUST HAVE AT LEAST TWO CONTACTS WITH AS MANY PHONE

NUMBERS AS POSSIBLE.

1. NAME: _______________________________________ RELATIONSHIP TO CHILD: __________________

PHONE # (AS MANY AS POSSIBLE): ___________________________________________________________

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2. NAME: _______________________________________ RELATIONSHIP TO CHILD: ___________________

PHONE # (AS MANY AS POSSIBLE): _____________________________________________________________

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BY SIGNING, I AGREE TO ALLOW MY CHILD TO ATTEND CAMP AMIGO FROM JULY

15-21, 2018. I UNDERSTAND THAT INAPPROPRIATE BEHAVIOR BY MY CHILD MAY RESULT IN

HIM/ HER BEING SENT HOME EARLY AT MY EXPENSE.

CAMPER’S SIGNATURE: _________________________________________________ DATE: ______________

PARENT’S SIGNATURE: __________________________________________________ DATE: ______________

CAMP AMIGO 2018MEDICAL INFORMATION

PLEASE FILL OUT COMPLETELY

HOW DID THE CAMPER RECEIVE THEIR INJURIES? ________________________________________

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IS THE CAMPER REQUIRED TO WEAR PRESSURE GARMENTS OR SPLINTS? Y___ N ____ If YES, PLEASE PROVIDE DETAILED INSTRUCTIONS FOR CARE____________________________

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DOES CAMPER HAVE ANY ARTIFICIAL LIMBS? Y____ N ___

IF YES, PLEASE PROVIDE DETAILED INSTRUCTIONS FOR CARE _____________________________

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PLEASE LIST ANY ALLERGIES (FOOD MEDICATION ETC.) THE CAMPER HAS __________________________________________________________________________________________________

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IS THERE ANY OTHER MEDICAL INFORMATION WE SHOULD KNOW ABOUT THE CAMPER? __

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**IF YOUR CHILD REQUIRES MEDICATION, PLEASE SEND ONLY ENOUGH FOR HIS/HER STAY AT CAMP WITH DETAILED INSTRUCTIONS AND IN

THE ORIGINAL CONTAINER**

THE MEDICAL INFORMATION PROVIDED IN THIS APPLICATION WILL ONLY BE AVAILABLE TO CAMP STAFF, IF NEEDED, AND TO MEDICAL PERSONNEL, IN CASE OF AN EMERGENCY.

BY SIGNING THIS FORM, THE PARENT/GUARDIAN IS GIVING THE CAMP DIRECTOR AND CAMP MEDICAL STAFF PERMISSIONS TO PROVIDE MEDICAL TREATMENT TO THE CAMPER (CHILD) IF IT IS NEEDED.

PARENT/GUARDIAN SIGNATURE: ________________________________________ DATE: ______________

Name of Medication and Dosage Times to be Given

****ALL MEDICATIONS MUST BE IN THEIR ORIGINAL CONTAINERS****

QUESTIONNAIRE

DID YOU COME TO CAMP IN 2017? IF YES, WHO WAS YOUR COUNSELOR? _____________________

WOULD YOU LIKE THE SAME COUNSELOR AS YOU HAD LAST YEAR? (THIS DOES NOT GUARANTEE THAT YOU WILL HAVE THE SAME COUNSELOR BUT WE WILL TRY EVERYTHING WE CAN FOR YOU TO HAVE THE SAME ONE) ______________________________

WHEN GOING TO CAMP, WHAT ARE SOME OF THE THINGS THAT YOU WOULD LIKE TO DO? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

ARE THERE ANY SPECIAL FOOD REQUESTS THAT WE NEED TO BE AWARE OF? (VEGAN, VEGETARIAN, ETC) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _____________________________________________________________________________________________

CAMP AMIGO 2018 July 15-21, 2018

*WAIVER AND RELEASE*

RELEASE TO USE PHOTOS AND/OR FILM

MY CHILD WILL BE ATTENDING CAMP AMIGO FROM JULY 15 THROUGH JULY 21, 2018 AND WILL BE PARTICIPATING IN ACTIVITIES OFFERED. I GIVE MY PERMISSION FOR CHILDREN’S BURN CAMP OF NORTH FLORIDA, INC. TO TAKE PHOTOGRAPHS (DIGITAL OR OTHERWISE) AND VIDEO FOOTAGE OF MY CHILD. I UNDERSTAND THAT PHOTOGRAPHS AND VIDEO THAT INCLUDE MY CHILD MAY BE USED TO PROVIDE THE GENERAL PUBLIC AND OTHERS INFORMATION REGARDING BURN INJURIES AND PREVENTION, AND TO INFORM THEM ABOUT CAMPS LIKE OURS.

LOCAL MEDIA FROM TALLAHASSEE, JACKSONVILLE, AND GAINESVILLE ARE INVITED TO ATTEND THE LAST FULL DAY AT CAMP. THERE IS A POSSIBILITY THAT YOUR CHILD WILL APPEAR ON THE TV NEWS OR IN THE PAPER, HAVING A GREAT TIME AT CAMP!

**A PARENT/GUARDIAN OF EVERY CHILD ATTENDING CAMP MUST SIGN THE RELEASE**

PARENT/GUARDIAN SIGNATURE: _______________________________________DATE: ________________

**THE PHOTOGRAPHS AND VIDEO TAKE AT CAMP WILL ONLY BE USED BY CHILDREN’S BURN CAMP OF NORTH FLORIDA, INC. (CAMP AMIGO) FOR THE PURPOSES STATED ABOVE.

PHOTOS AND VIDEO WILL BE TAKEN DURING ALMOST EVERY ACTIVITY BY CAMP STAFF AND OTHER CAMPERS. WE DO NOT ALLOW OTHER ENTITIES OR PERSONS ON THE

PREMISES, UNLESS SPECIFICALLY APPROVED AND INVITED. **

CAMP AMIGO 2018JULY 15-21, 2018

CAMPERS MINIMUM STANDARDS OF CONDUCT

THESE STANDARDS HAVE BEEN DEVELOPED TO PROTECT CHILDREN’S BURN CAMP FO

NORTH FLORIDA, INC. (CAMP AMIGO) IT’S VOLUNTEER COUNSELORS AND ITS CAMPERS.

ALL CAMPERS MUST READ AND ADHERE TO THE FOLLOWING RULES. ANY CAMPER THAT

VIOLATES THESE RULES OR ANY OTHERS SET FORTH DURING THE COURSE OF CAMP.

MAY BE ASKED TO LEAVE CAMP IMMEDIATELY AND MAY NOT BE INVITED BACK TO CAMP

THE FOLLOWING YEAR.

• NO ALCOHOL OR ILLEGAL SUBSTANCES OF ANY KIND WILL BE PERMITTED.

• NO FIREARMS OR WEAPONS OF ANY KIND. THIS INCLUDES: GUNS, KNIVES,SLINGSHOTS, FIREWORKS, OR ANY OTHER ITEM THAT COULD BEHARMFUL TO THE CAMPER OR OTHERS.

• NO FIGHTING. THIS INCLUDES VERBAL AND PHYSICAL FIGHTING. IFTHERE IS A PROBLEM WITH ANOTHER CAMPER, PLEASE FIND A STAFFMEMBER AND THEY WILL RESOLVE THE PROBLEM.

• NO ENTERING OTHER CAMPERS’ OR COUNSELORS’ LIVING AREA WITHTHEIR PERMISSION.

• NO DISTURBING OTHER PEOPLE’S PROPERTY WITHOUT THEIR CONSENT.

• NO DISPLAYING OR PRESENTING MATERIAL, SONGS, ACTIVITIES, ORMESSAGES THAT DEGRADE, INSULT, OR FRIGHTEN OTHERS, OR THAT ARE

AT THE EXPENSE OF OTHERS. (BE NICE!!!)

• NO INAPPROPRIATE ATTIRE. THIS MEANS NO SUGGESTIVE CLOTHINGINCLUDING BATHING SUITS.

• YOU ARE REQUIRED TO SMILE AND LAUGH OFTEN AND HAVE A GOODTIME!!!

WITH MY PARENTS/GUARDIANS I HAVE COMPLETED THE CAMPER APPLICATION AND HAVE

READ AND UNDERSTAND THE RULES FOR MY CONDUCT AT CAMP. I WILL TAKE

RESPONSIBILITY FOR MY ACTIONS AND CONDUCT MYSELF IN A MANNER THAT ENSURES MY WELL-BEING. I WILL EXERCISEGOOD JUDGEMENT IN ALL MY ACTIONS AND I WILL

FOLLOW THE RULES AND COOPERATE WITH THE CAMP STAFF BECAUSE THEY ARE THERE

FOR MY SAFETY.

MOST IMPORTANTLY, I UNDERSTAND THAT IF I DO NOT FOLLOW THE RULES, I MAY BE

SENT HOME EARLY AND I MAY NOT GET TO COME BACK TO CAMP NEXT YEAR.

CAMPER’S SIGNATURE: _______________________________________________ DATE: _________________

PARENT/GUARDIAN SIGNATURE: ________________________________________ DATE: ______________

WHAT TO EXPECT & WHAT NOT TO EXPECT

WHAT TO EXPECT

TO WALK A LOT

TO SPEND A LOT OF TIME TOGETHER AS CAMPER AND COUNSELOR TO BE ON YOUR BEST BEHAVIOR

TO TRY MANY DIFFERENT THINGS

TO LEARN A LOT ABOUT OTHERS AND YOURSELF TO BE EXHAUSTED

TO BE FRUSTRATED AT TIMES

TO HAVE YOUR SENSITIVITY TESTED TO LAUGH HARDER THAN YOU EVER HAVE BEFORE

TO MISS HOME AND SOMETIMES WONDER IF YOU SHOULD HAVE COME

TO FOLLOW THE RULES TO DO THINGS YOU’VE NEVER DONE BEFORE

TO BE SAD WHEN IT’S TIME TO SAY GOODBYE

WHAT NOT TO EXPECT

TO HAVE OTHERS PICK UP AFTER YOU

TO HAVE A LOT OF PRIVACY TO EVER REGRET YOUR CAMP EXPERIENCE

TO EVER FORGET YOUR CAMP EXPERIENCE

SIGNATURE: ___________________________________________________ DATE: _______________

Camp Amigo Policies

Alcohol

• The possession or consumption of alcohol by anyone regardless of

location is prohibited.

Tobacco

• The use of tobacco by campers is prohibited. The use of tobacco by

adults is only in designated areas and shielded from campers.Illegal Drugs/ Weapons

• The possession of any substance/ weapons will not be tolerated.

Camp Boundaries

• Campers and counselors must stay on designated trails. Campers and counselors must be together in all designated areas of Nantahala Outdoor Center.

Curfew

• Campers must be in their designated cabins at lights out. Counselors

may be outside the cabin but there must be at least two counselors

inside the cabin while campers are asleep.Cabin Assignments

• At no time will male campers be allowed in female cabins or female

campers are allowed in male cabins. Cabins will be kept neat. We are

responsible for damages to cabins. Counselors should report any

damage to staff immediately. The A/C in cabins is set and IS NOT to

be tampered with.Privacy

• Privacy of campers and counselors is important and should be

respected. Avoid any actions, comments or information that may place

the camper or counselor in an embarrassing or uncomfortable

situation. (i.e. comments regarding weight, speech pattern, gender,sex, race, color, religion, etc.) Also remember that this is communal

living and therefore there is no expectation of true privacy.

Touching

• Never touch a camper or counselor on a part of the body normally

covered by a bating suit or in any way that makes them

uncomfortable.

Raiding

• Raiding of rooms is prohibited. Though raids may be considered fun,

they always end up messing up someone’s personal stuff, damagingfacilities, and wasting resources.

Being on time

• Our schedule at camp is very laid back. So on the few occasions we do

have a designated meeting time, it is important that you and your

camper be on time.

Signature: ______________________________________________ Date: _____________

CAMP AMIGO 2018 SCAR MANAGEMENT WORKSHOP MEDICAL RECORD

Therapeutic Massage Medical Record

Name: ___________________________________________________________ Date: __________________________

Address: _________________________________________________________________________________________

Parents Home Phone Number: __________________________ Work Phone Number: ___________________________

Cell Phone Number: _______________________________ E-mail address: ___________________________________

Occupation: _____________________________________ M/F: ____ Age: ____ Date of Birth: ____________________

Best way to contact you: Call home ____ cell ____ work ____ E-mail ____ Text ____

Has your child ever had a therapeutic massage before? Yes, No If yes, how many times? ____

Please indicate any of the following medical conditions/symptoms that you have had:

____ Allergies ____ Fibromyalgia ____ Muscle Strain ____ Angina ____ Frozen Shoulder ____ Osteoporosis ____ Arthritis ____ Headaches ____ Phlebitis/Thrombosis ____ Asthma ____ Heart Disease ____ Pregnancy ____ Auto-Immune Disorder ____ Hepatitis ____ Sciatica ____ Backache ____ High Blood Pressure ____ Scoliosis ____ Bleeding Disorder ____ Infection ____ Seizure Disorder ____ Cancer ____ Kidney Disorder ____ Skin condition/Infection ____ Carpal Tunnel Syndrome ____ Liver Disorder ____ Stroke ____ Chest Pain ____ Lyme’s Disease ____ Varicose Veins ____ Diabetes ____ Meningitis ____ Whiplash Injury ____ Disc Problems ____ Migraines

Please list any significant injuries, illnesses, or surgeries? (Please be specific)

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Please list any medications you are taking and what condition they are used to treat:

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On the figures at the right, please indicate any areas of pain, tightness, swelling, numbness, injury, or infection. Massage is contraindicated under certain medical conditions. I affirm that I have stated all my child’s known medical conditions and answered all questions honestly. I understand that there shall be no liability on the practitioner’s part should I fail to do so.

Signed: ______________________________ Date: __________ I understand that my child will be receive therapeutic massage by licensed health care massage therapists under the supervision of three instructors. I give my permission as parent/guardian for my child to receive a therapeutic session for their burn scars. Signed: ______________________________ Date: __________

CAMP AMIGO 2018 SCAR MANAGEMENT WORKSHOP MEDICAL RECORD

Burn Medical History

Date of Burn: __________________________

Injury Location(s): __________________________________________________________________________________

Skin Grafts / Donor Sites / Open Wounds? Yes _____ No _____

Location on body ______________________________________________________________________________

What areas can be touched? ________________________________________________________________________

What areas cannot be touched? _____________________________________________________________________

Prostheses? _____________________________________________________________________________________

On the figure below, indicate location of burn(s), skin graft site(s), donor site(s), open wounds, and areas you would not

like touched:

What is/are your chief symptoms: ____ Pain ____ Itching ____ Tightness ____ Weakness ____ Joint Contracture

____ Depression ____ Anxiety ____ Grief ____ Anger ____ Other __________

Additional Information:

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Additional information:

• Rain jacket and pants• Baseball cap or wide-brimmed sun hat • Wool/fleece hat (spring and fall)• Fleece jacket (spring and fall)• Gloves (spring and fall)• Extra pair of glasses or contacts if you wear themOptional: Modest cash allowance for souvenir item or snack

Group AdventuresThanks for planning an adventure with NOC! We’re excited to see you. Here are our recommendations on what to bring.When packing, keep the following guidelines in mind:

What to Wear For…

• Long or short-sleeved shirt made out of synthetic or wool material (not cotton)• Board shorts or nylon shorts• Swimsuit• Water shoes or sandals with a heel strap• Sunglasses or glasses with a strap

• Long pants or shorts (longer-length shorts are better suited for wearing a harness while zip lining and for riding a bike)• Long or short sleeved shirt• Socks• Tennis shoes • Closed-toe and closed-back for zip line activities

• Shorts, T-shirt and socks that you don’t mind getting very muddy• Old tennis shoes• Plastic bag to store wet, muddy clothes.

• Long sleeved cotton shirts• Short sleeved T-shirts or comfortable shirts (cotton is okay)• Extra socks• Shorts• Long pants• Underwear• Pajamas • Sports bra• Headlamp or flashlight• Batteries• Water bottle• Toiletries• Necessary prescription medications• Sleeping bag• Sleeping pad (Not necessary in NOC’s cabins, inn or bunkhouse lodging)• Towel• Sunscreen & lip balm• Bug spray• Plastic bag to store wet or dirty clothes• 1 clean outfit for your return trip

Whitewater Rafting Lake, Paddle Boarding & Kayaking:

Zipline, Alpine Tower, Tree Climbing, Mountain Biking Hiking & Wilderness Survival Skills:

Adventure Mud Race:

Overnight Trips:

Strongly Suggested:

• Adjust the number of items you pack according to how many days you will spend with us and what activities you have planned.• NOC’s mountain location means you may experience a wider range of temperatures than you’re used to. Check the forecast, and consider a layering strategy where you can add/remove clothing as needed, especially in the Spring and Fall. Even summer trips can get chilly if it rains, so be prepared.• Please leave your valuables at home—you won’t need jewelry, makeup, fancy clothing or electronic devices.

NOC’s on-site Out�tter’s Store and Wesser GeneralStore carry many of these items. However, there is noguarantee of item or size availability, so please comeas prepared as possible.

01674019.2

For NOC use only

Activity Date: Rsv Party Name:

Activity Time: Rsv #:

Activity Type: # in Party:

RELEASE OF LIABILITY/LIABILITY WAIVER FORM

FULL LEGAL NAME of PARTICIPANT: _________________________________________________________________________

ADDRESS: _________________________________________________________________________________________________

CITY, STATE, ZIP: _________________________________________ PHONE: __________________________________________

EMAIL: _______________________________________________________________

PRINT Full Name of Emergency Contact: ______________________________

Relationship of emergency contact: ____________________________ Phone(s) of Contact Person: __________________________

Activity Participation Acknowledgement

I, the undersigned, hereby acknowledge that I am participating in an activity for which Nantahala Outdoor Center, LLC, a Georgia limited

liability company or one of its subsidiaries (individually and collectively, “NOC”) is furnishing equipment or services and which requires

physical exercise, including, without limitation, rafting, kayaking, swimming, stand-up paddle boarding, rock climbing, hiking, rappelling,

zip-lining, ropes course navigating, or cycling (the “Activity”). By signing this waiver, I certify that I am in good health and physical

condition and do not suffer from any disability which would prevent my participation in the Activity. I agree to abide by any decision of any

NOC employees, organizers, volunteers, directors, representatives, agents, and officers (collectively, the “NOC Parties”) regarding my ability

to safely participate in the Activity. I fully understand that I may injure myself as a result of my participation in the Activity and that certain

injuries may result in death or permanent physical disability. I also acknowledge and agree that my participating in any Activity may be

terminated immediately if any of the NOC Parties believe, in their sole discretion that I am unable to complete the Activity for any reason or

that I am under the influence of alcohol or drugs.

Risk Acknowledgement, Indemnity and Release

In consideration of my participation in the Activity, I hereby assume all risks, known and unknown, associated with participation in the

Activity including, but not limited to, any injuries resulting from falls, contact with other participants, the conditions of Activity sites, bodily

injuries and death. To the fullest extent permitted by law, I hereby agree to indemnify, hold harmless and defend the NOC Parties, as well as,

where applicable, the Tennessee Valley Authority, Ocoee Outfitters Association, the state of Tennessee, the U.S. Forest Service, the United

States of America and other any federal or state governmental agencies or other entities who may have an interest in any river, lake, or other

real property or waterway on which the Activity takes place (individually and collectively, the “Indemnified Parties”) from and against any

and all claims, losses, damages, expenses and other liabilities (including, but not limited to, court costs and attorney’s fees) arising out of or

resulting in whole or in part from my participation in the Activity. I for myself and anyone entitled to act on my behalf, including, but not

limited to my heirs and successors, hereby RELEASE, WAIVE AND FOREVER DISCHARGE the Indemnified Parties from any and all

claims, losses, damages, expenses and other liabilities of any kind arising out of my participation in the Activity even if such claims, losses,

damages, expenses and other liabilities arise out of negligence or carelessness on the part of any or all of the of the Indemnified Parties.

Media Release

I hereby grant and convey to the NOC Parties all right, title and interest I may have in any and all photographs, motion pictures, video

recordings, and any other recordings made during or about the Activity, and the NOC Parties shall have the right to exploit such recordings

throughout the universe, an unlimited number of times, in perpetuity by any and all means and media, now known or hereafter invented.

Medical Emergencies

I hereby give permission to the NOC Parties to contact emergency services for help, whether or not the NOC Parties have contacted my

emergency contact, and give permission to a licensed physician or other licensed medical provider to provide proper treatment, including but

not limited to hospitalization, injection, anesthesia and/or surgery. I hereby RELEASE, WAIVE AND FOREVER DISCHARGE the NOC

Parties from any and all claims, liabilities, causes of action, damages, demands, judgments, executions, liens and costs whatsoever in law or

equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any (i)

claims made against medical providers of emergency services under this authorization, or (ii) against the NOC Parties for obtaining

emergency medical services for me pursuant to this authorization and waiver.

______________

Date Your Signature

If you are under the age of 18, your parent or guardian must execute this form on your behalf.

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Date Your Parent’s or Guardian’s Signature

Check if you do not want to be occasionally contacted about NOC offers and promotions.