MPH Camper Registration Packet Page 1 Please return completed Paperwork to: Make Promises Happen, #1 Twin Cedar Lane, Guthrie, OK 73044-7041 Name Phone Number Name Phone Number Name Phone Number Roommate Requests (we try to honor, no guarantee): 1) _________________ 2) _________________ 3) __________________ The people listed below may drop off/pick up camper. *Please contact the office if this information changes.* 1) ___________________________ (_____)_____-_____________ 2) ___________________________ (_____)_____-_____________ Accompanied by Caregiver? Contact office if changes. Yes No ____________________ (_____)_____-_____________ Check T-Shirt size: Youth S M OR Adult S M L XL 2XL 3XL 4XL 5XL Other: _________ Date: __________________________ MM / DD / YYYY Last First Middle MM / DD / YYYY Camper Name: ___________________________________________________________ Nickname: ____________________________ Male Female Camper legally known as: ___________________________________________________________________ New Camper Returning Camper Date of Birth: ______________________ Age: ___________ BASIC CAMPER INFORMATION Primary Disability: _____________________________________ Secondary Disability: _____________________________________ Camper requires one-on-one assistance: Yes No If yes, please explain: ________________________________________ Camper E-Mail, if any: __________________________________________ Camper phone, if any: (_______)________-____________ Referral Source: Advertisement Camp Resource Fair Word of Mouth Friends School Internet Sibling Whom do we thank for the referral? ___________________________________________________________________________________ OPTIONAL Camper is from which one of the following ethnic groups (please check most predominant ethnic group): African American, Black Native Hawaiian or other Pacific Islander Hispanic, Latino Asian American Indian/Alaskan White, not Hispanic Name home work cell home work cell Name home work cell home work cell Camper is own guardian Name/s of camper’s guardian/s, if not camper: _____________________________________ _________________________ (_____)_____-_____________ (_____)_____-_____________ E-Mail of guardian: ____________________ _________________________ (_____)_____-_____________ (_____)_____-_____________ E-Mail of guardian: ____________________
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MPH Camper Registration Packet BASIC CAMPER INFORMATION · MPH Camper Registration Packet Page 1 Please return completed Paperwork to: Make Promises Happen, #1 Twin Cedar Lane, Guthrie,
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MPH Camper Registration Packet
Page 1 Please return completed Paperwork to: Make Promises Happen, #1 Twin Cedar Lane, Guthrie, OK 73044-7041
Name Phone Number Name Phone Number
Name Phone Number
Roommate Requests (we try to honor, no guarantee): 1) _________________ 2) _________________ 3) __________________
The people listed below may drop off/pick up camper. *Please contact the office if this information changes.*
Initials: _______ Photo Release: I hereby give consent for participant to attend and participate in all programs and activities of Central Oklahoma Camp and the
Make Promises Happen program. Pictures, audio tapes and videotapes may be taken of participant for use in publicity that is in the proper inter-
est of Central Oklahoma Camp and the Make Promises Happen program. I will alert COC&CC/MPH staff if camper is in state custody and can-
not be photographed, due to lack of consent or other reasons.
Initials: _______ Field Trips/Transportation: I understand that the program may include not only normal activities conducted at Central Oklahoma Camp, but may
also include field trips and multi-day trips which may require transportation to and from locations, and trips which will involve walking and hiking
away from Central Oklahoma Camp. I hereby give permission for participant to participate in any and all such activities, which are super-
vised and deemed appropriate by qualified camp personnel.
Initials: _______ Activities: I understand that participant may take part in activities on the campground that could include a climbing wall, ropes course training,
archery, swimming, canoeing and other such activities of Central Oklahoma Camp and the Make Promises Happen program. I do hereby agree to
indemnify and hold Central Oklahoma Camp and the Make Promises Happen program and its agents, servants and/or employees harmless from any
and all damages, claims, expenses or costs of whatever nature, causes of action, suits and liability of every kind including attorney fees, for injury to or
death of participant or for damages to any property, arising out of or in connection with participant's use or occupancy of the premises or participation in
activities at Central Oklahoma Camp and the Make Promises Happen program, except where such injuries, misfortune, accident, or damages are
caused in whole or in part by the negligence of Central Oklahoma Camp and the Make Promises Happen program, or joint negligence of any
person or entity hired or contracted by Central Oklahoma Camp and the Make Promises Happen program.
Initials: _______ Cancellation of Participation: I understand that if I have misrepresented or failed to inform Central Oklahoma Camp and the Make Promises
Happen program of any special needs or disabilities that participant has, that Central Oklahoma Camp and the Make Promises Happen program may not
be able to provide appropriate support. If this situation occurs, I understand and agree that Central Oklahoma Camp and the Make Promises Happen
program will terminate participation in the program and I understand and agree that if participant must leave program because of un-
disclosed issues that no money will be refunded to me.
Initials: _______ I hereby give my permission for Certified Medication Administration staff to give medication to the camper
while at camp or recreation program. The 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 health care provider 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 health care provider to hospitalize, secure
proper treatment for, and order injection, anesthesia, or surgery for this camper. I understand the medical information provided will be shared on
a "need to know" basis with camp staff. I give permission to photocopy the packet. In addition, the camp has permission to obtain a copy of my
camper’s health record from providers who treat my camper and these providers may talk with the program’s staff about my camper’s health
status. I understand that I will be contacted, at the emergency numbers listed on the registration form, by the camp staff once emergency medical
treatment has been secured.
Initials: _______ Cancelation Policy: I understand that refunds and/or deposit credits will only be applied if notification is given to camp office at least 1 week (7
days) prior to the event.
Initials: _______ E-mail Communication: I understand that my name will be added to a web service in order that I will receive communications via E-Mail, if I
provided an E-Mail address for communication purposes (fundraising, camp calendar and registration of events, etc.). I understand that I can alter
my subscription from the web service at any time, that it is my responsibility to update the camp with any changes to my contact information, any
information that I provided.
Initials: _______ Sharing of Information: I give Central Oklahoma Camp and Conference Center/Make Promises Happen permission to share my name and con-
tact information with support groups, agencies and organizations, camper families. I understand that camp will not share sensitive information, such
as diagnosis, medical, financial, etc. Furthermore, I understand that the purposes of sharing the information would be to provide support to other
campers, their families and guardians, and for returning any missing items that went home with another camper.
The camper and the guardian shall protect, hold free and harmless, defend and indemnify Central Oklahoma Camp & Conference Center and the Make Promises
Happen program (including its officers, agents, volunteers and employees) from all liability, penalties, costs, losses, damages, expenses, causes of action, claims or judg-
ments (including attorneys' fees and/or fines and penalties) which arise out of, or are in any way connected with the performance of the work and/or services provided
under this contract. This agreement shall apply to any acts or omissions, negligent conduct, whether active or passive, including acts or omissions, injury, damage
and/or loss of property and misfortune or accident on the part of named child or their agents and/or representative. EXCEPT that this agreement shall not be appli-
cable to injury, misfortune, accident or damage to property arising from the sole negligence of Central Oklahoma Camp & Conference Center and the Make Promises
Happen program, its officers, agents, volunteers and employees.
Signature of Legal Guardian/Agent Acting on Behalf of the Legal Guardian: Date: