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Camper Application
2023 TRAC Camper Application
TRAC Camp Dates
Boy's camp: June 29th, (Arrive at 8AM at Compassion Church-Statesboro) - July 2nd, (Pickup at 4PM at Compassion Church)
Girl's camp: July 6th, (Arrive at 8AM at Compassion Church-Statesboro) - July 9th (Pickup at 4PM at Compassion Church)
READ THIS BEFORE FILLING OUT THIS APPLICATION
The following information should be helpful to you as you complete your application:
The application, interview and training process for camp volunteers is rigorous. As you look through the application you will notice that we require a variety of specific information, all of which we consider necessary to help us to to serve the camper and provide the best experience for him/her.
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For the protection of campers who have experienced abuse in their lives, we have rigorous systems in place for all volunteers including criminal background and reference checks, detailed training and strict rules and procedures at camp. We have a licensed nurse and behavioral specialist at each camp to ensure the campers safety at all times.
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This camp is operated as a ministry of Hope Rising Georgia sponsored by Compassion Christian Church. As such, all volunteers will fall under the authority of the Camp Leadership as trained by the National TRAC offices and under the authority and beliefs of Compassion Christian Church
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Please complete all sections of the forms as honestly as you can. No camper will be denied based on behavioral issues. We recognize that in some cases sensitive and confidential information is required. We value your confidentiality and strive to limit access of all written and verbal information you may provide to those who need to know.
Section 1 of 6
Camper Information
What is your camper's full name? *
Biological Sex *
What is your camper's birth date, current age, and emotional age? *
Camper's Shirt Size & Shoe Size (adult sizes) *
Name of Camper's Case Worker
Case Worker's Phone Number
Case Worker's Email Address
Name of Case Worker's Supervisor
Supervisor's Phone Number
Supervisor's Email Address
Name of Person Camper is Living With (Relation to Camper)
Length of Time Camper as been in this home?
What is the camper's address? *
What is your phone number?
What is your email address? *
What is a good emergency contact name and number? *
Maintaining a safe environment for our campers and volunteers is our number one priority, but accidents do happen.
Section 2 of 6
Camper Personality
Check the boxes which best describe the camper most of the time. *
Please check all that apply.
Section 3 of 6
Emotional & Behavioral History
Agression/Anger *
Please select an option.
Bedwetting *
Please select an option.
Biting *
Please select an option.
Eating Disorder *
Please select an option.
Hyperactive *
Please select an option.
Lying *
Please select an option.
Nightmares *
Please select an option.
Runs Away *
Please select an option.
Sexual Acting Out *
Please select an option.
Stealing *
Please select an option.
Withdrawn/Sad *
Please select an option.
Please explain any behaviors that occur often and describe how they are handled
Section 4 of 6
Emotional & Behavioral History
Doctor's Name/ Facility/ Phone Number *
Medical Insurance Name/ Insurance Number *
Name of Counselor/Psychologist & Phone Number *
Immunizations Up to Date? *
Please select an option.
If no, what immunizations is the camper missing?
Date of Last Tetanus Booster (TDAP)? *
Does Camper Have Seasonal Allergies *
Please select an option.
Does Camper Have Any Food/Drug Allergies?
Please select an option.
If so, please describe
Does Camper Carry an EpiPen?
Please select an option.
Please list ANY known medical conditions (mental or physical), illnesses or surgeries treated by a doctor in the last year
Does the Camper Have Any Physical Disabilities or Limitations?
Please select an option.
If yes, please describe
Is the Camper Diabetic?
Please select an option.
Does the Camper Have Asthma?
Please select an option.
Is the Camper Pregnant?
Please select an option.
Please list ALL medications the camper is taking. Please list Name of Medication, Reason for Medication, Dosage (amount), and Time Given.
Note: medications must be in original prescription bottles from prescribing physician. This is not the time to give medication vacations
Section 5 of 6
Permission to Administer First Aid & Over-the-Counter Medications
I hereby give the Teen Reach Adventure Camp Nurse permission to administer first aid and the following products according to manufacturer's instructions, or as otherwise specified.
I trust the TRAC Nurse to use his/her best judgement as situations arise, and if in doubt, he/she can call for verification.
A check means: Yes, I give permission for that product
Please check all that apply.
Section 6 of 6
Medical & Liability Release
MEDICAL RELEASE: This health history is correct so far as I know, and the above-named minor has permission to engage in all prescribed program activities. The undersigned does hereby authorize TRAC, on behalf of the undersigned, to consent to an X-ray examination., anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above minor, which is deemed advisable by, and to be rendered under the general or special supervision of any physician/surgeon, licensed under the provision of the Medical Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis treatment is rendered at the office of said physician or dentist, at a participating in any camp program, unless revoked in writing by the undersigned and delivered to the Camp Director. During camp, prescription medication will be administered to youth as directed by a physician. TRAC will do everything in its power to prevent incorrect medication from being given. However, the local TRAC/ Teen Reach. DBA TRAC/ Teen Reach Adventure Camp, is not liable for incorrect medication provided to us by the legal guardian, incorrect dosages given, nor is it liable for wrong labeling on medicine bottles. Legal guardians are responsible for checking in the correct medication, bottles, and dosages at the time of registration. This is not the time to give medication vacations to your teen.
LIABILITY RELEASE: Every precaution will be taken to protect campers and volunteers from harm, but the local TRAC/Teen Reach/ DBA TRAC/ Teen Reach Adventure Camp is not liable for injuries/death that youth or volunteer staff may incur while camping or participating in TRAC activities. If he/she is injured, I have given medical information and permission to take him/her to a medical facility for proper care. All extension activities are included in the liability release. I release the local TRAC/ Teen Reach/DBA TRAC/ Teen Reach Adventure Camp, from any liability surrounding any injuries/death to camper and/or the camper/s unborn child if the camper is pregnant.
As the legal guardian of the above youth, I agree that all the information provided in this application is accurate. I also agree to both the medical and lability releases and the permission to administer first aid and over-the-counter medications as indicated in Section 5.
NOTE: AT CAMP REGISTRATION, MEDICATIONS MUST BE IN ORIGINAL PRESCRIPTION BOTTLES FROM PRESCRIBING PHYSICIAN. THIS IS NOT THE TIME TO GIVE MEDICATION VACATIONS.
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Check the box the degree to which the camper has displayed the following emotions/behaviors in the past 12 months. Please answer honestly. (Negative behaviors do not disqualify a camper from attending camp)
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