Fillable NYPD APPLICATION PACKET (Sac and Fox Nation)

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NYPD APPLICATION PACKET (Sac and Fox Nation)

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Annual

Camp

Experience

June 11-15,

2018

Camp

Takatoka

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.

Sincerely,

NYPD Staff

Contact Representative: _____________________________________________________

Phone Number: ____________________________________________________________

E-Mail: ___________________________________________________________________

Complete

Registration

Forms Should

Be Returned to

Your Contact

Representative

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.

Housing

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

Food

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

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.

Visitation

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.

Behavior

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

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 girl’s 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)

- Pajamas or extra shirts for sleeping

- 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

- “TOTALLY 80’S” COSTUME

A dance will be held the final evening of camp. The theme is

“Totally 80’s”. Campers should bring a 1980’s themed costume.

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 _____________________________

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:

Food

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)

Fillable NYPD APPLICATION PACKET (Sac and Fox Nation)

Fill Online, Printable, Fillable, Blank NYPD APPLICATION PACKET (Sac and Fox Nation) Form

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