Hey Buddies! Thank you for applying to Camp Bloomfield’s buddy program. Buddies will sign up according to their school grade. The buddy program gives sighted kids an opportunity to volunteer and participate along side the legally blind campers allowing them both to share each other’s experiences. Space is limited for this unique program during the Youth Development and Elementary/Junior Camp sessions. In addition, the buddy of a blind or visually impaired camper has priority. All sessions will incorporate sports, music, and of course all the traditional camp activities such as archery, arts and crafts, horseback riding, swimming, and the climbing wall and ropes course. Attached are Step 1 and 2 of the registration process. Complete Step 1 (forms 1 through 7) and return them ASAP along with the $125 registration fee and a 2x2” face picture (mandatory) and copy of the participant’s medical insurance or Medi- Cal card to tentatively hold a space in the session. Your application will be time stamped in the order received. Note: The physical examination stamped by a licensed physician and TB test is valid for 2 years. The tetanus shot is valid for 10 years. Example: Camper Frankie has a physical dated June 1, 2011. Frankie’s physical is valid until June 1, 2013. There is a, non-refundable $125 registration fee per sighted buddy. Submit a check or money order made payable to: Junior Blind. If either step is incomplete, you will be placed on stand-by. Once both Step 1 and 2 are complete, you will receive a confirmation letter by mail or email. Please invest the time to read the included Camp Handbook to better assist you in the registration process and for additional information needed for a smooth transition into camp.
5300 Angeles Vista Boulevard Los Angeles, California 90043 Phone: 323-295-4555 Fax: 323-296-0424 www.juniorblind.org
Buddy Application applies to a sighted child in the 2nd-8th grade. Buddy may only apply to one session. Please return Step 1 of the application ASAP, to tentatively hold a space in the session. Due to limited availability, it is very important that you take a proactive approach and follow through quickly. Note: If the participant attended summer camp 2012, your file will be retrieved to verify if we can use any portion of the medical records (the medical records must be current within 2 years), therefore, we will be able to use it for this upcoming summer 2013. If any portion is expired you will be notified with an alert letter, advising you to get new medical records. Return to: yrivas@juniorblind.org
REGISTRATION PACKET_”BUDDY”
(Please Type or Print in BLUE or BLACK ink)
Youth Development Camp: Elementary/Junior Camp:
______________________________ ______________________________ ______________________________
______________________________ ______________________________ ______________________________
EMERGENCY: ADDITIONAL CONTACT IN EVENT PARENT(S)/ GUARDIAN(S) CANNOT BE REACHED
Signature of parent/guardian: X _____________________________________________ Date: __________________ Form # 1 (Information_Buddy_2013) Camp Bloomfield BUDDY/PARENT/GUARDIAN MEDIATION AND ARBITRATION AGREEMENT
This is an Agreement to mediate and arbitrate all unresolved disputes arising from the educational, recreational, special education school, and residential services between the undersigned student and/or their legal guardian and the Junior Blind of America. In the event of any unresolved dispute, claim or controversy by the student and/or their legal guardian against Junior Blind, its directors, officers, employees or agents, the student and/or their legal guardian agrees to submit such unresolved dispute, claim or controversy, including but not limited to all claims for breach of contract and civil torts, to non-binding mediation before a neutral independent third-party mediator and, if that process does not result in full resolution of the dispute, to final and binding arbitration, including, but not limited to, claims for breach of contract and civil torts. The arbitration shall be conducted by a single-arbitrator selected either by mutual agreement of the student and/or their legal guardian and the Junior Blind or, if they cannot agree, from an odd-numbered list of experienced arbitrators provided by the American Arbitration Association. Each party shall strike one arbitrator from the list alternately until one arbitrator remains. The arbitrator shall have all powers conferred by law and a judgment may be entered on the award by a court of law having jurisdiction. The award and judgment shall be in writing and binding and final on both parties. Each party shall have the right to conduct reasonable discovery, as determined by the arbitrator and as provided in California Code of Civil Procedure Section 1283.5(a). The parties agree to submit any unresolved dispute or unresolved controversy arising out of or relating to the terms of the Agreement to mediation, and if that process does not result in full resolution of the dispute to final and binding arbitration by a single neutral arbitrator. Junior Blind agrees to pay for 75% of the costs of the mediation and arbitration proceedings and the fees of the arbitrator. The remaining 25% of the costs and fees of the mediation and arbitration will be paid by the student and/or their legal guardian. Recognizing that parties involved in any such dispute may have limited resources, the parties agree to endeavor in good faith to identify a mediator and an arbitrator whose fees and costs are reasonable and affordable in light of that fact. This agreement shall continue during the period of service delivery and thereafter regarding any related disputes. This agreement may only be modified for the Junior Blind by a written agreement signed by the President of the Junior Blind. The student and/or their legal guardian understand that by signing this Agreement, he/she gives up his/her right to a civil trial and his/her right to a trial by jury. If any of the provisions of this Agreement are found null, void, or inoperative, for any reason, the remaining provisions will remain in full force and effect. I have read, understand, and received a copy of this document. Print name of BUDDY: ________________________________________________________________________ Print name of parent/guardian: ____________________________________________________________________ Signature of parent/guardian: X__________________________________________ Date: ____________________ Signature of Authorized Representative for Junior Blind (Don Ouimet, Vice President of Programs): X_________________________________________________________________ Date: ____________________
FORM # 2 (Mediation Arbitration Agreement_Buddy) Camp Bloomfield
“BUDDY”
MEDIA RELEASE
Permission is hereby given to JUNIOR BLIND® to use audio, video recordings, photographic and electronically created images of _________________________ (Buddy’s name) for public view, including publications, websites or social media sites. Usage of any images or audio is without compensation to said person or to the undersigned on his/her behalf, or individuality. On occasion, specific students are identified for profile stories used in grant applications and reports, publications, websites or social media sites. Permission is hereby given to JUNIOR BLIND® to publish in grant applications and reports, publications, websites or social media sites, _________________________ (Buddy’s name) story with related quotes, after verbal and/or written approval of that story has been granted by said person or by the undersigned on his/her behalf or individuality. Address: ______________________________________________________________________ City, State, Zip Code: ____________________________________________________________Phone: _______________________________________________________________________ Print Parent or Guardian’s Name: __________________________________________________ Signature of Parent or Guardian: _____________________________ Date: ________________
INCOME INFORMATION
Please answer the following questions as they apply to your household. 1. How many people live in your household? _________________________________________ 2. What is your household’s combined gross annual income from all sources $______________
FORM # 3 (Media Release_Buddy) Camp Bloomfield
“BUDDY”
ACTIVITY OPT-OUT
I have crossed-out the following activities in which I DO NOT want my child to participate in:
Archery, Golf, Arts & Crafts, Climbing Wall, Ropes Course, Hiking, Horseback Riding, Drama, Tandem Bikes, Outdoor Living Skills, Swimming/ Instruction (Pool), Swimming (Beach), Evening activities, Nature, Beep Baseball, Goal ball, TeePee Overnighter, Extended Hiking, and/or Other:__________________________________ Please note: All buddies, regardless of swimming ability, are required to take the swim test and pass in order to access the deep end of the pool (5-10ft). BUDDY’S swimming ability (circle one): [Non-Swimmer] [Beginner] [Intermediate] [Advanced] I hereby grant BUDDY named above permission to participate in all activities offered by or through Camp Bloomfield, with the exception of those activities that were crossed-out above. The undersigned parent, guardian, or custodian of the above named BUDDY hereby joins in the foregoing Activity Opt-Out Form and hereby stipulates and agrees to save and hold harmless, indemnify, and forever defend Camp Bloomfield, their directors, officers, agents, employees, and volunteers from and against any claims, actions, demands, expenses, liabilities (including reasonable attorney fees) for negligence as a result of said BUDDY’S participation in the activities of Camp Bloomfield and his or her use of the property, animals, and facilities. I, on behalf of said BUDDY, further agree not to sue Camp Bloomfield, its directors, officers, agents, employees, and volunteers as a result of any injury that said minor suffers from negligence in connection with his/her participation in the activities of Camp Bloomfield. I represent that said BUDDY have no health or physical condition that will interfere with the activities stated above or cause him/her to be more susceptible to injury than the average person. If any health conditions are present, I assume the risks associated with any such health or physical condition. Print name of parent/guardian: ____________________________________________________________________ Signature of parent/guardian: X__________________________________________ Date: ____________________ AUTHORIZED RELEASE OF BUDDY
Buddy’s Last Name:________________________________ First Name: __________________________________ Session ________________________________________ I hereby authorize the following persons to check-in my child during registration, pick up my child at the end of the session, or in the event of an emergency: (Please print)
First Name: ____________________ Last Name: _____________________ Relationship: ____________________ First Name: ____________________ Last Name: _____________________ Relationship: ____________________ First Name: ____________________ Last Name: _____________________ Relationship: ____________________ Signature of parent/legal guardian: _________________________________ Date: ________________________
When picking up the buddy, the person authorized must show a valid state ID or Drivers License. FORM # 4 (Activity Publicity_Buddy) Camp Bloomfield
“BUDDY”
Please read the following information very carefully. Select one arrival option and one departure option and sign at the bottom of the form. -------------------------------------------------------------------------------------------------------------------------------------------- ARRIVAL OPTION (Select one)
Junior Blind 5300 Angeles Vista Blvd., Los Angeles, CA 90043
Buddy will be checked-in at Junior Blind Gym (Back Gate off of 54th St.) the first day of the session at 8:00amSHARP. If camper arrives late, JBA is not responsible for transporting to Camp Bloomfield. Camp Bloomfield 35375 Mulholland Hwy., Malibu, CA 90265
Buddy will be checked-in at Camp Bloomfield on the first day of the session at 4:00pm sharp. LAX/Oxnard Transportation Center
Buddy will arrive via LAX Airport or Oxnard Transportation Center on the first day of the session between 8am-10am (No Exceptions will be made!). MANDATORY: I will include a copy of the itinerary and “Travel Reservation Confirmation” in addition to filling out this form.
Junior Blind
Buddy would like to take the Camp Bus from Camp Bloomfield to Junior Blind and be checked-out on the last day of the session at Junior Blind (Back Gate off of 54th St.) at 10:30am. If you arrive late, buddy will return to camp. It will be the parent/guardian’s responsibility to pick up buddy at Camp Bloomfield. Camp Bloomfield
Buddy will be checked-out on the last day of the session from Camp Bloomfield between 8:30am -10am. LAX/Oxnard Transportation Center
Buddy will depart via LAX Airport or Oxnard Transportation Center on the last day of the session between 8am-10am (No Exceptions will be made!). -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
I have carefully read and clearly understand the procedure regarding arrival and departure. Buddies ages 5-14 must be checked-in and checked-out during the times posted above by a parent/guardian. Cabin and counselor assignments will only be given after buddy has been properly checked-in and registration is complete. Print name of parent/guardian: ___________________________________________________________________ Signature of parent/guardian: X__________________________________________ Date: ____________________
FORM # 5 (Arrival and Departure_Buddy) Camp Bloomfield
“BUDDY”
AUTHORIZATION FOR TREATMENT OF BUDDY CONSENT, RELEASE, AND COVENANT
The undersigned parent/guardian represents to Junior Blind that the minor named below is in his and/or her legal custody and control; and that the undersigned desires said minor to participate in the programs of Junior Blind, and that for purposes of said participation the undersigned agrees, authorizes and states as follows: In case of medical or dental need or emergency, I (we) understand every effort will be made to contact parents/guardians of children. In the event I (we) cannot be reached, I (we) undersigned, parents/guardians of buddy, do hereby authorize Junior Blind and its officers or staff employees as agent(s) for the undersigned to obtain and consent to any X-ray examination, anesthetic, medical, dental, surgical diagnosis, treatment and hospital care which is deemed advisable by, and is to be rendered to said minor under the general or special supervision of any surgeon licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital or by a dentist licensed under the provisions of the Dental Practice Act, whether such diagnosis of treatment is rendered at the office of said physician or dentist or at the said hospital. I (we) also understand and agree that any and all such medical, dental, hospital or similar expenses incurred in the treatment of my (our) child will be borne by myself (ourselves,). We understand that no representation of such coverage exists or is intended by this form. It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment or care being required but is given to provide authority and power on the part of Junior Blind (as aforesaid) as my (our) agent(s), to give specific consent to any and all such diagnosis, treatment or care which a licensed physician or dentist in the exercise of his/her best judgment may deem advisable. The authorization is given pursuant to the provisions of Sections 25.8 of the Civil Code of California. This authorization shall remain effective while the child is enrolled in Junior Blind’s Recreation Programs, unless sooner revoked in writing and delivered. The undersigned further releases Junior Blind, its officers, agents, and employees from any and all legal responsibility for accidents or sickness occurring during or related to the period of time said person is a participant in programs of Junior Blind. I (we) further agree and covenant (for valuable consideration, receipt of which is acknowledged) that neither said person or I (we) will institute any suite or action of damage, loss or injury of any kind, whether to person or property, whether to me (us), individually, or as parents/guardians relating to the programs or activities of Junior Blind (including but not limited to Camp Bloomfield) in which the person participates. Parent/guardian Initials _____ Current Medical Insurance is mandatory in order to participate in any recreation activity or event. Any medical costs incurred while participating in any Junior Blind’s Recreation Program (Camp Bloomfield) shall be the responsibility of the participant’s parent or guardian. Medical costs include: physician visit, emergency room visit, prescription medication, and/or emergency transportation. It is also to be understood and agreed that any and all such medical, dental, hospital, or similar expenses incurred in the treatment of the participant will be borne solely by the parent or guardian. If a situation requires medical treatment, the parent or guardian will be contacted by a staff member and informed of the situation. Should a situation arise where the parent or guardian cannot be reached, the participant will be taken to the local emergency facility for treatment. Parent/guardian Initials _____ I have carefully read information above, clearly understand, and voluntarily sign this Form agreement. I HAVE READ AND WILL PROVIDE A COPY OF: MEDICAL INSURANCE CARD State of California/Benefits Identification Card (MEDI-CAL) Print name of parent/guardian: ____________________________________________________________________ Signature of parent/guardian: X__________________________________________ Date: ____________________
FORM # 6 (Treatment Consent Release_Buddy) Junior Blind HEALTH HISTORY QUESTIONNAIRE_”BUDDY”
All questions contained in this questionnaire are strictly confidential
and will become part of your medical record (Please Type or Print in BLUE ink). All documentation must be in English.
Last Name: First Name: PERSONAL HEALTH HISTORY List any medical problems that other doctors have diagnosed Surgeries Does the participant have a disability (besides vision) or chronic illness? HEALTH HABITS AND PERSONAL SAFETY Exercise:
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
participant may consume:
Has participant had any eye treatments or surgeries? If yes, please explain.
Cause of Visual Impairment: Traveling needs: Does participant use a white cane?
Does participant wear glasses, contacts, or other optical aids?
Self-help skills (independently): Shower? Physical Limitations:
Does participant have trouble walking/standing for long periods of time?
Can participant run for long periods of time?
Is participant developmental y delayed? please explain:
FORM # 7 (Health History Questionnaire_Buddy) Junior Blind IMPORTANT INFORMATION
Does participant usual y get up to urinate during the night? If yes, number of times _____
Does participant have problems eating or has eating disorders?
Has participant ever seriously thought or attempted to hurt oneself?
FOR MINOR FEMALES: (NOT ADULTS)
If not, does participant have knowledge of menstruation?
ALLERGIES
Vegetarian: [] No pork [] No beef [] No chicken [] No fish [] No sea food [] No dairy [] Other: __________________________
HEALTH HISTORY
Check if participant has or has had any problems in the following areas to a significant degree and briefly explain:
Seizures—Date of last episode: / /
FORM # 7 (Health History Questionnaire_Buddy) Junior Blind
Please feel free to add any additional information or special notes for the camp nurse that will enhance the buddy’s experience at Camp Bloomfield: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I hereby grant permission for camp nurse to dispense over the counter medications to camper as needed such as: Tylenol, Motrin, Benadryl, Robitussin, Claritin, Sudafed, Dramamine, Vitamin C, Cepacol Lozenges, Maalox, Pepto
Bismol, Milk of Magnesia, Metamucil, Cortisome Cream, Antifungal Cream, Neosporin Ointment, Hydrogen Peroxide,
Saline, Iodine and Alcohol swabs to clean and prepare skin.
Please circle one: YES or NO
Please print parent/guardian name: _________________________________________________________________
Signature of parent/guardian: X _________________________________________ Date: ______________________
Please refer to the attached information sheets. All buddies within grades 5th through 8th must submit a current
physical (within 24 months of the end of the session/s which they are attending) completed and signed by a licensed
physician. In addition, all camp participants, regardless of age must submit proof of current TB test (within 24 months
of the end of the session/s which they are attending) and tetanus shot (within 10 years). Registration is complete only
after you have paid the $125 fee and all of your paperwork is complete. You will receive a confirmation letter once all
of your paperwork & fee are received. I certify that the above information is true to the best of my knowledge. I also understand that my camp registration
packet must be submitted to the Recreation Department.
Please Submit Step 1 NOW, do not wait to submit it along with Step 2
Please print parent/guardian name: __________________________________________________________________
Signature of parent/guardian: X _________________________________________ Date: _______________________
STOP, this section must be completed in the presence of the camp nurse during check-in: I have discussed
my concerns with the camp nurse and have disclosed buddy information to the nurse to ensure a safe and healthy
stay at Camp Bloomfield. Signature of parent/guardian: X _________________________________________ Date: ______________________
Signature of Camp Nurse: X ____________________________________________ Date: ______________________
FORM # 7 (Health History Questionnaire_Buddy) STOP! STEP 1 MUST BE SUBMITTED BEFORE YOU CONTINUE!
Form 8 must be signed and stamped by a licensed physician, along with a current TB test (within 24 months of the end of the session/s attending) and tetanus shot (within 10 years of the end of the session/s attending).
Form 8 must be submitted ASAP in order to receive a confirmation letter.
Return to: yrivas@juniorblind.org Junior Blind PHYSICAL EXAMINATION_”BUDDY”
All questions contained in this exam are strictly confidential
and wil become part of your medical record. All documentation must be in English.
Buddy’s Name: Date of Birth: Address: Doctor’s Date of physical examination: MEDICAL EXAMINATION MUST BE FILLED OUT AND SIGNED BY A LICENSED PHYSICIAN Buddy’s
Height______ Weight______ Blood Pressure__________
Surgeries Year Reason Other hospitalizations
List all prescribed medications and over-the-counter medications used regularly (include vitamins and inhalers). Allergies to medications FORM # 8 (Physical Examination_Buddy) Junior Blind PLEASE INDICATE ANY ABNORMALITIES AND EXPLAIN, OR INDICATE IF WNL HEALTH HISTORY (FOR ANY YES ANSWER, INDICATE ONSET DATE, AND ANY CURRENT LIMITATION.)
Head/Brain injuries, disorders or illnesses:
Ear disorders, loss of hearing or balance:
Heart disease or heart attack, other cardiovascular condition:
Missing or impaired hand, arm, foot, leg, finger, toe:
Lung disease, emphysema, asthma, chronic bronchitis:
Nervous or psychiatric disorders (e.g., severe depression):
Does participant have a history of seizures?
If yes, please check: Grand mal______ Petite mal_______ Date of last seizure: / /
Uncorrected Corrected Horizontal Field of Vision
Physician’s Signature: X
License or Certificate Number/Issuing State:
This form must be stamped by a licensed medical facility in order to be considered valid
Place Licensed Physician Stamp in this Space. FORM # 8 (Physical Examination_Buddy) Junior Blind This form must be stamped by a licensed medical facility in order to be considered valid
Tuberculosis Assessment INTRADERMAL SKIN TEST (WITHIN 2 YEAR)
Date Read: Mm induration: ____________mm Impression: negative positive Technician:
If positive, Must provide last chest x-ray (within 2 years)
Film date: Impression: Normal Abnormal Technician:
Tetanus Injection Date of Tetanus injection within the last ten years. _____-_____-_____ (Mandatory) Initials:____
PLEASE PROVIDE A COPY OF RECENT IMMUNIZATION RECORD Place Licensed Physician Stamp in this Space. FORM # 8 (Physical Examination_Buddy)
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STOP! STEP 1 MUST BE SUBMITTED BEFORE