W.A.N.G.

Y Wednesday 2011
July 6 – Aug 10, 2011
Camper Registration Form

Campers Name_______________________________

Health Insurance & Policy #:_________________________________

I. EMERGENCY MEDICAL TREATMENT

I authorize the W.A.N.G.Y Wednesday 2011 program staff to administer
minor first aid as needed and to request the assistance of a Medical
Center’s Emergency Room personnel and Ambulance when necessary.

My child is up to date on all immunizations. (A copy of immunizations is

provided)
_______________________________________________________
Parent Signature Date

II. PERMISSION TO MEDICATE:

This authorization form is required to be signed by the physician and the
parent/guardian of any child who must receive medication during
W.A.N.G.Y Wednesday. Please put medication in a Ziploc baggie clearly
labeled with youth’s name in original medication container. Submit
medications to camp nurse upon arrival at camp.
Name of Physician:____________________ Phone:__________
Name of Medication:_______________________________________
Time and Dosage of meds to be
taken:___________________________________________________
________________________________________________________
________________________________________________________
TO THE PARENT/GUARDIAN: The health of each camper is primarily the
responsibility of the parent(s)/guardian(s). Our goal is to provide a full
camping experience for all campers. To help us achieve this goal, we ask
each applicant to inform us if there are any health concerns.
Parent/Guardian
Signature:______________________________________________

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III. Special health needs Camp Nurse’s and Staff or emergency personnel
should know prior to any treatment______________________
_______________________________________________________
_______________________________________________________
Date:___________ Physician Name:___________Phone: __________
Physician
Signature:___________________________________________
(attach any special notes if needed)
Date:____________ Parent/ Guardian Name:__________________
Parent/Guardian
Signature:____________________________________________

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Campers Name: __________________________________________

CAMP WILL PROVIDE THE FOLLOWING NON-PRESCRIPTION

MEDICATIONS:
I authorize the following medications to be administered under supervision of the Camp Nurse as
needed:
Tylenol Benadryl
Y N Y N
Chloraseptic Sudafed
Y N Y N
Cough Syrup Gas-X
Y N Y N
Mylanta Cough Drops Sunscreen
Y N Y N
Pepto Bismol Insect Repellant
Y N Y N
Ibuprofen Topical insect and minor scrape
Y N medication Y N

Allergies: List all known/Describe reaction and management of

reaction:_________________________________________________
________________________________________________________
Food Allergies: List all known/Describe reaction and management of
reaction:_________________________________________________
________________________________________________________

*Any potentially fatal allergies ie. Bee stings/peanuts

etc:_____________________________________________________
________________________________________________________

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IV. Photo Release Form
I hereby grant permission to the staff at “W.A.N.G.Y. Wednesday 2011” to photograph my child’s
experience at Camp and use printed publication in any manner deemed necessary. I also acknowledge
that they might not use photos at this time but may do so at their own discretion at a later date. I
understand that no names will be used of youth in photos. Photos are used to promote camp and for
future funding possibilities.

________________________________________________________________________
Signature of parent/guardian. Date

V. HOLD HARMLESS AGREEMENT

Upon completion of this registration packet, I acknowledge that although the

Staff of W.A.N.G.Y. Wednesday 2011 and the Washington Air and Army National
Guard program have taken precautions to provide proper organization, supervision,
instruction and equipment for its programs, it is not possible for the program to
guarantee absolute safety.

I recognize the need for my child and me to assume our share of responsibility
for ensuring safety in the W.A.N.G.Y. Wednesday 2011 program, held at Camp
Murray in Tacoma, WA.

I recognize that all youth attending camp will be signed up for 4-H so that all
participants will be covered by liability insurance should an accident occur.

Therefore, I hereby waive and release Camp Murray, W.A.N.G.Y. Wednesday 2011
and its staff from all claims or demands arising out of such participation.

__________________
Camp Member’s Name
__________________ ______________________
Parent Printed Name Parent/Guardian Signature
__________________
Date

W.A.N.G.Y Wednesday 2011

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VI. CODE OF CONDUCT
As a participant in WANGY Wednesday 2011, you are expected to conduct
yourself in a manner that brings honor to you, your family, the military
community and the camp.

Camp Member Expectations:

1. All rules set forth during camp must be followed at all times.
2. Leaving campgrounds without permission is prohibited.
3. Dress appropriately for each activity. Adults in charge will have
guidelines to help you.
4. Attend all sessions in the planned program. Arrive at least ten minutes
before role call is scheduled to begin. If you are not feeling well, please
tell an adult in charge.
5. Profanity and vulgar language is prohibited.
6. Possession and/or use of tobacco, alcohol products and/or illegal
substances are prohibited.
7. Treat program areas, lodging areas, and transportation vehicles with
respect and care. You will be responsible for any damage, theft, or
misconduct in which you participate.

As a participant in WANGY Wednesday 2011, I have read the WANGY

Wednesday GOALS and CODE OF CONDUCT expectations and agree to
abide by them.

________________________________________________________
Camp Member Printed Name Parent Printed Name

_________________________________________________________
Camp Member Signature Parent Signature