FIRE Camp 2019
Saturday, May 18th
Campers: Grades 6-8 Peer Leaders: Grades 9-12

Campers arrive 7:45-8am, non-overnight pick-up is 10pm. Overnight pick-up is Sunday, 8:30-9am

This form is in three sections: Registration, Liability Waiver and Behavior Code. It is used for students in grades 6-12.
Adult volunteers can register here: https://www.signupgenius.com/go/30E0A4DA8A723A1FC1-fire

Email address *
Cannot pre-fill email address.
Student First Name *
Your answer
Student Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Current Grade *
Student Cell Phone (high school students only)
Your answer
High School only (select the time frame)
Sex
Do you want to stay overnight? (grade 7 and 8 only--only possible with enough chaperones) *
T-Shirt Size *
Sandwich Choice (for lunch) *
I would like to be in a group with.... (list one friend)
Your answer
I would like to go to a specific location (list one resident)
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone *
Your answer
Additional Parent Phone
Your answer
Student Home Street Address *
Your answer
Student Home City, State, Zip *
Your answer
Email address *
Cannot pre-fill email address.
Section 2-Medical and Media Release
This is the waiver portion of the form and must be completed by a parent/guardian.
Doctor and insurance information is needed to complete this section.
The parish will take reasonable care to see that the following information will be held in confidence.
I grant permission for my child listed above to participate in the FIRE Camp event organized by St. John Nepomucene from May18, 2019 to May19, 2019 (for those who stay overnight). If the event is offsite, I also grant permission for my child to be transported by any means of official transportation organized by St. John Nepomucene or their representatives *
Required
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. John Nepomucene Parish/School, its officers, directors, employees and agents, and the Diocese of Green Bay, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, its officers, directors and agents, and Diocese of Green Bay its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Diocese of Green Bay. *
Required
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.) EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. *
Required
In the event of an emergency and you are unable to reach me, please contact: *
First and Last name; relationship to child
Your answer
Emergency Contact Number of the above person *
Your answer
Child's Family Doctor *
Your answer
Phone number of the Doctor *
Your answer
Family Health Plan Carrier *
Your answer
Insurance Policy #: *
Your answer
Medications: My child is taking medication at present (leave blank if there are no medications). My child will bring all such medications necessary and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows
Your answer
Please check ONE of the Following *
Does your child have allergic reactions (medications, foods, plants, insects, etc.)? If yes, explain in detail. *
Your answer
Does your child have a medically prescribed diet? If yes, explain in detail
Your answer
Does your child have any physical limitations? If yes, explain in detail
Your answer
You should be aware of these special medical conditions of my child:
Your answer
MEDIA RELEASE: This authorization form constitutes permission for my child’s participation in videotaping and/or photographs which may be taken during the program/trip. These could be used for further promotional videos, website promotions, fliers, or other diocesan or parish appropriate uses. *
I verify the information above is correct and further submit this form. *
Required
Email address *
Cannot pre-fill email address.
Behavior Code
The FIRE Camp Planning Committee would like your child to have the most positive experience possible when they attend FIRE Camp this year. Therefore, we believe it is beneficial to have parents and campers know ahead of time what our expectations are as far as behavior, and what the consequences will be, if these expectations are not met.

Please discuss this section with your child before signing below. Please talk about RESPECT with your child. We want camp to be an enjoyable and rewarding experience for every person involved. In order for this to happen, everyone needs to have RESPECT for each other. This is why we ask students to leave electronics at home. Part of being RESPECTFUL is to be present and willing to talk with each other. This is hard to achieve when students are on their devices. We are all God’s creation and deserve RESPECT.

Expectations
•No Bullying-absolute zero tolerance
•Everyone is dressed with modesty (shirts must be long enough and have sleeves, pants must stay up and cover undergarments)
•No Electronic devices, including ipods, cell phones, video games, etc. Cameras are allowed.
•Respect-to other campers, to high school peer leaders, to the adult team leaders, to the homeowners/guests, camp volunteers and anyone else they encounter that day.
Cell Phone Use
•If students have them, they will be asked to put them away.
•We want all participants, campers and leaders, to engage in each other and the homeowner. Taking time to check phone messages takes away from the community aspect.
•In case of emergency, you will be notified by the FIRE Committee or adult leader with your child.
Consequences: If problems arise, there is a 3 strike policy.
• Strike One- the problem is addressed to the student and he/she is asked to change behavior
• Strike Two-if problems continue, parents will be called and notified of the issue
• Strike Three-if behavior does not improve and issues continue, parents will be asked to pick their child up
We (parent and child) agree to the above expectations and consequences of FIRE Camp to allow each camper to have the best experience possible. *
Required
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