June 11-15,
Choteau, OK
Dear Parents,
Thanks to our coalition of sponsors, we are proud to host the annual Native Youth
Preventing Diabetes (NYPD) program at Camp Takatoka, a YMCA camp near Choteau,
Oklahoma. NYPD offers the tools necessary for our native youth to reduce the risk of
developing chronic disease. In addition to offering a traditional camp experience, NYPD also
provides instruction on the importance of nutrition, physical activity, self-esteem and diabetes
prevention in a five day, four night experience. We encourage you to review the information
that follows for yourself, as well as with your child.
Attendance at NYPD is limited to Native American children between the ages of 8 and
12 years old. Campers stay with campers of the same sex and of similar age. Qualified YMCA
counselors will be stationed in each cabin. Volunteers from each of our coalition members will
work very hard to make sure each camper has an opportunity to learn and have a great time.
NYPD is a place for safe, wholesome fun and learning. Thank you for considering sharing
your camper with us. If you have any further questions, please contact your coalition
representative listed below.
NYPD Staff
Contact Representative: _____________________________________________________
Phone Number: ____________________________________________________________
E-Mail: ___________________________________________________________________
Forms Should
Be Returned to
Your Contact
May 18, 2018
This organization is an equal
opportunity provider
Camp Takatoka
Camp Takatoka is an overnight camp on
Ft. Gibson Lake. At Takatoka, campers
experience 410 acres of land with
diverse geography including lakefront,
grass plains, rolling hills, cliffs, caves and
forest. This is truly a place where your
child is sure to create lifelong
friendships and memories.
NYPD Activities
- Arts & Crafts - Archery - Basketball
- Canoeing - Climbing Wall - Fishing
- Hiking - Ropes Course - Swimming
- Volleyball - Cultural Activities
NYPD Staff also educate campers on:
- Nutrition - Self-Esteem
- Physical Activity - Diabetes Prevention
Campers attending NYPD are expected to comply with all camp policies and procedures. We ask that all
parents read the important information that follows and review the information with your camper.
Campground Care
The care of the camp is the responsibility of all in attendance. Campers will be asked to assist in maintaining a clean campground. Chores
include trash pick-up, sweeping buildings, and set up for and clean-up after meals.
Campers are responsible for keeping a clean cabin and will be involved in the daily “Clean Cabin” competition. Each day, cabins are
inspected by NYPD staff to determine which group has the most well-kept cabin. Winners are recognized daily for their efforts. Campers will be
assigned to cabins with other campers of the same sex and similar age. All cabins have bunk beds, electricity, air conditioning, and shower and
restroom facilities. Qualified YMCA counselors will be stationed in each cabin
In order to aid in the prevention of ants, mice and other rodents, no food is allowed to be brought into the camp. NYPD staff will be
tasked with searching the belongings of all campers prior to camp attendance for food. Any food found by staff will be confiscated and returned
to the parent prior to boarding for transportation to camp or upon arrival at the campground. Be assured, all campers will receive three properly
balanced meals a day, served family style in the dining hall as well as a snack in the morning and afternoon. Coalition volunteers providing
transportation to and from camp will communicate to parents all plans to provide meals and drinks during transportation times.
Electronics devices are not permitted on campgrounds. NYPD staff will be tasked with searching the belongings of all campers prior to
camp attendance for electronic devices. Any devices found by staff will be confiscated and returned to the parent prior to boarding for
transportation to camp or upon arrival at the campground. Electronic devices include: cell phones, tablets or other computer devices, digital
media players, radios, hair dryers, curling irons, walkie talkies, etc. Cameras will be allowed with disposable cameras preferred.
In the best interest and safety of the campers, parents/guardians/visitors will NOT be allowed in camp during session without prior
approval from the NYPD infirmary staff. Campers that leave the campground will not be allowed to return.
Health & Safety
The health and safety of our campers is of high importance. Drugs, alcohol, cigarettes, fireworks, firearms, knives or weapons of any kind
are not permitted. NYPD staff will be tasked with searching the belongings of all campers prior to camp attendance for items considered to be a
safety concern. Any items found by staff will result in loss of camp attendance privileges. Campers will not be allowed to board transportation
for nor allowed to enter the campground.
In order to ensure the health of campers and camp facilities, all campers will be screened for head lice by NYPD staff upon arrival at
camp facilities. Campers found to have evidence of head lice may not be allowed to attend camp. Thus, NYPD recommends that campers
planning to attend be screened for head lice two weeks prior to camp attendance to allow proper time for treatment. This pre-screening may be
required according to each coalition group’s policy.
It is our goal to have a fun and comfortable experience for all campers, as a result we expect campers to abide by behavior policies.
Campers are expected to be on time for all activities. The buddy system should be practiced at all times. Any public display of affection on the
part of a camper is prohibited.
Every camper has a right to attend NYPD without being subjected to threat of injury or intimidation in any fashion. Incidents of fighting,
physical assault, verbal intimidation and other negative offenses that reference sex, age, color, religion, national origin, or disability are not
acceptable. In addition, all staff and campers must be allowed to live in an environment free from unsolicited harassment. Harassment is
behavior which is not welcome, which is personally offensive, which debilitates morale and which interferes with the living environment of all
campers. A safe and friendly atmosphere is the responsibility of all campers and staff.
Discipline Policy
You and your child should understand that while participating in camp, the staff is in charge. Your child should be aware that any rules
and or instructions that are made by a staff member are to be respected. In the unlikely event that there is a disciplinary problem that cannot be
resolved, the parent will be notified and expected to pick up his/her child immediately. It is likely that your child will not be allowed to
participate in future camps.
Homesickness is normal. Rest assured that our staff is trained to recognize it and will employ methods to get campers back on track. If
homesickness becomes extreme, such as not eating or crying all the time, you will be contacted and allowed to talk to your camper to reassure
them or pick them up if necessary.
Dress Code
Clothing should be comfortable and appropriate for all camping situations. Any campers who bring inappropriate clothing and persist in
trying to wear inappropriate clothing will be sent home without refund. The following are NYPD dress code requirements:
- Closed toe shoes and socks must be worn at all times. Socks must reach the ankle or above
- Sandals/flip flops are only to be worn when showering or at the swimming pool.
- No mesh, short-waist, tube, halter, low neck or spaghetti strapped shirts are allowed.
- Sleeveless shirts should not expose girls bras or cleavage or boy’s pectoral area, should have shoulder seams at least 3’ wide and should
keep the chest area unexposed when leaning over.
- No shirts advertising alcohol, cigarettes or questionable practices, or any clothing with a suggestive design or words.
- Pants, jeans, shorts, etc. are to be worn at the waist line and belts are to be buckled. Low rise shorts or jeans may be worn only when
the shirt extends over the top of the jeans or shorts.
- Short length must reach the tip of the fingers when arms are by the side. Bike shorts or spandex type shorts are not allowed.
- Pants should be free from holes in the seat.
- Bathing suits will be modest. No string bikinis or thongs will be allowed.
- Jewelry should be limited to studs in the ears. Other pierced jewelry must be removed.
- Tattoos must be concealed except during swimming.
What to Pack
We ask all belongings be clearly marked with the camper’s name. Washers and dryers are not available at the camp.
- Shirts (refer to dress code)
- Shorts (refer to dress code)
- Jeans/long pants or sweats (refer to dress code)
- Underwear
- Socks (refer to dress code)
- Closed toed shoes (tennis shoes, hiking boots, etc.)
- Shoes appropriate for use at waterfront, when showering, or
during swim time
- Jacket or raincoat
- Hat for sun protection
- Swimsuit (refer to dress code)
- Sleeping bag or twin sized sheets, blanket & pillow
- Towels & washcloths
- Flashlight with extra batteries
- Plastic cup or water bottle
- Insect repellant
- Sunscreen (minimum SPF 15 recommended)
- Camera & film
A dance will be held the final evening of camp. The theme is
Registration information is required to be filled out in its entirety and returned to your coalition contact prior to
the registration deadline.
Name of Camper: _____________________________________________________________________________
Attended NYPD Before? Yes No If yes, when? _____________________________________________
Date of Birth: __________________ Age At Camp: ________________ Gender: Male Female
T-Shirt Size: Youth S M L XL Adult S M L XL 2XL 3XL
Parent/Guardian Name: ________________________________________________________________________
Address: _____________________________________________________________________________________
City: ________________________________________ State: _____________ Zip Code: _________________
Home Phone: _________________________________ Work Phone: ___________________________________
Cell Phone: ___________________________________ E-Mail Address: ________________________________
Preferred method of contact: ____________________________________________________________________
Emergency Contact: _____________________________ Relationship to Camper: _________________________
Phone Number:_______________________________________________________________________________
NYPD’s mission is to educate, promote, and empower future generations of Native American children in the awareness of diabetes
and its complications. The programs and activities that your child will participate in through this summer camp experience we hope
will help achieve our mission. In order to evaluate our programs overall success, feedback from our campers is extremely valuable.
Do you authorize NYPD and/or its coalition of sponsors to contact you and your camper in order to receive
feedback regarding our program at a later time? Yes No
Medical Information
Immunization History:
Please attach a current shot record to this application. In order to attend camp, all immunizations must be current according
to the recommended CDC schedule. Please indicate if immunizations were not given due to medical reasons.
Please list family members that have a history of diabetes:
Relation to Camper _______________________ Relation to Camper _____________________________
Relation to Camper _______________________ Relation to Camper _____________________________
Child’s Routine Physician/Medical Facility:________________________________________________________
Phone Number: ______________________________________________________________________________
Has the camper menstruated? (Females Only) Yes No Date of last menstruation: ________________
Will your child require medications during camp? Yes No
NOTE: All medication must be turned in to camp staff at check in. All medication must be in original container with the
camper’s name and physician’s directions for use.
Please list all medication/s and frequency administered:
Please indicate any allergies your child may have:
Medication Insect Animals Plant Other
Please list the allergy and describe the reaction observed.
Please list any previous surgeries, including date.
Does your child have any activity limitations? Explain.
Does your child require any dietary modifications? Explain.
Does your child have an illness, special need, or disability that camp staff should be aware of? Explain.
Camper & Parent Pledge
Parent: I have read and agree with the NYPD policies and procedures and have discussed them with my child. I understand that my
child must abide by the rules and policies while at camp or I may be requested to pick up my child before the completion of camp
without refund and that my child may not be eligible for future camps or activities.
Parent Signature: _________________________________________________________
Camper: On my honor, I declare that I understand the NYPD policies and procedures and agree to abide by them. I also agree to
participate and represent my sponsor to the best of my ability.
Camper Signature: ________________________________________________________
Consent and Release
Release of Information
I hereby authorize the release of information obtained during the health screening of ________________________________
to the NYPD coalition and its partners. I understand my child’s information will be maintained in a database by NYPD for the
purposes of data analysis, tracking health status’ of camp participants, identifying high risk individuals for treatment, and creating,
targeting or maintaining education programs and funding.
__________________________________ ___________________________________________ ________________________
Parent/Guardian Name Parent/Guardian Signature Date
Health Care Screening Consent and Release
I understand that _____________________________________ will be screened for head lice prior to attendance at NYPD.
Children found to have a positive screening may not be allowed to attend camp.
I further understand and agree that during camp, NYPD, its employees, volunteers, staffers, and/or others providing services
to NYPD, may provide the following health care screening services to my child, if I consent to such screening, which may involve the
collection of my child’s health information: weight, height, body fat percentage, blood sugar, cholesterol, ALT/AST, blood pressure,
emotional health, health knowledge and health behaviors measurement. Blood work will be performed through a finger stick. I
understand that screeners may recommend or suggest to me that I seek medical care for my child based upon the limited
information obtained in this health screening and that this does not constitute medical care or treatment. I also understand that this
information may be analyzed and shared, in a non-identifiable format, to further the services of NYPD and its affiliates or sponsors. I
hereby authorize screeners to perform the above screening services on my child and release and hold harmless the screeners for any
injury incurred as a result of voluntarily allowing my child to participate in the screening.
__________________________________ ___________________________________________ ________________________
Parent/Guardian Name Parent/Guardian Signature Date
Camper Contact/Safety
I understand that for the safety of _________________________________________ and the other children at camp, should I
need to contact my child during camp, I must first contact the NYPD Supervisor. I also understand that if I should have to take my
child from the campgrounds for any reason, my child cannot return to camp without prior approval from the NYPD Supervisor.
I understand that safety and respect of campers are priorities for NYPD and Camp Takatoka staff. I understand that violent,
threatening or aggressive behaviors will not be tolerated. I grant permission for proper intervention by NYPD or Camp Takatoka
staff, up to and including physical restraint if necessary, in the case of aggressive, threatening or violent behavior exhibited by my
child. I further understand that these behaviors are reason for immediate expulsion from all camp activities.
__________________________________ ___________________________________________ _______________________
Parent/Guardian Name Parent/Guardian Signature Date
Permission to Medicate
I, as parent or guardian of, ____________________________________________ a camper attending NYPD summer camp,
give my permission to NYPD health staff to give my child the medications identified in this registration document. I understand all
medications must be in original containers with clearly labeled instructions for use. I further understand medications not in original
containers or lacking medical instructions for use may not be administered while at camp.
I also consent to transporting, seeking emergency treatment and making decisions regarding welfare of my child, such as
medication and health assessments, if necessary, while he/she is participating in NYPD. I further authorize NYPD medical staff to
administer or apply any of the following medications or generic versions thereof to my child, if needed or requested: topical itch
relief including Benadryl, hydrocortisone, Calamine lotion; allergy relief including Benadryl/antihistamine, pseudoephedrine;
asthma/respiratory relief including albuterol inhaler or inhalation solution; anti-diarrheal; wound care including Bacitracin or triple
anti-biotic ointment, hydrogen peroxide; throat pain relief including Chloraseptic spray or lozenge; diabetic/hypoglycemic crisis relief
including Glucagon; pain relief including ibuprofen, Tylenol; stomach upset relief including Kaopectate, Mylanta, Maalox, Tums;
cough relief including Robitussin DM; emergency care including smelling salts or Epipen.
__________________________________ ___________________________________________ ______________________
Parent/Guardian Name Parent/Guardian Signature Date
Media Release
I understand that ___________________________________________ may be photographed or videotaped while in
attendance at NYPD camp. I further understand that my signature below hereby grants ownership of any picture or likeness or
anything derived therefrom created by NYPD, its agents and others working for it or on its behalf for use in promotion of NYPD. I
shall have no right of approval, no claim to additional compensation and no claim (including without limitation, claims based upon
invasion of privacy, defamation or right of publicity) arising out of any uses, alteration, distortion or illusionary effect or use in any
composite form.
__________________________________ ___________________________________________ _____________________
Parent/Guardian Name Parent/Guardian Signature Date
Consent and Release of Liability
I understand that ____________________________________________ will be participating in supervised activities including
but not limited to, arts and crafts, archery/rifle, nature activities, swimming, outdoor skills, basketball, volleyball, softball, rock wall
climbing, canoeing, hiking, fishing, and Native American cultural activities. I recognize that there are inherent risks and hazards
directly or inherently involved in these activities, with some activities considered dangerous activity with the potential to cause
serious injury. With full knowledge of the facts and circumstances surrounding these activities, I voluntarily grant permission for my
child to undertake these activities and I assume all responsibility and risk for my child’s participation in these activities.
I assure NYPD that there are no health-related reasons or problems which preclude or restrict my child’s participation in
these activities. I authorize the on-site medical personnel to treat my child as appropriate in the event of any injury/illness. I grant
permission for NYPD, and/or employees, agents, staffers, volunteers or others providing services to NYPD.
I, the undersigned, also hereby release NYPD staff, its affiliates or sponsors of any liability in the event of accidental injury,
illness or death during their attendance at NYPD.
__________________________________ __________________________________________ _____________________
Parent/Guardian Name Parent/Guardian Signature Date
Registration Fee
The fee for attendance at NYPD is $____________ per child.
This fee is non-refundable and payment is due at the time of registration.
June 11-15, 2018
Native Youth Preventing Diabetes (NYPD)