The Cathedral Domaincamp & conference center

800 Highway 1746 Irvine, KY 40336 (606) 464-8254 www.cathedraldomain.org

the episcopal diocese of lexington

2013 Camp Registration

PLEASE PRINT ALL INFORMATION (except signature)

Name of Camp/Session: Camper's Name: Sex: Male Female Date of Birth: Youth Med Youth Large Small Preferred Name: SSN: Medium Large XL X

T-Shirt Size: Church Name: School Name:

Grade Just Completed:

Parent/Guardian Name: Street Address: City: Home Phone: Cell Phone: Cell Phone: Work Phone: Work Phone: State: email: Contact Name : Contact Name: Contact Name: Contact Name: Yes No No Zip:

Has your child previously attended The Cathedral Domain? Yes - Name of Church & Community:

Is the camper, parent/guardian or grandparent an Episcopalian in the Diocese of Lexington?

By signing below I indicate that I have read, understand and agree to the participation, photograph and rooming policies.
___________________________________________________________________________ Parent/Guardian Signature ______________________________________________ Date

Please enclose appropraite camp fees: Mini Camps - $195.00 All other Sessions - $375.00 add $25 if registering within 2 weeks of your camp session Scholarship amount requested: I would like to help another child attend camp. Enclosed is my scholarship donation for the following amount: $10 $25 $50 $100 $195 $375 other: To pay camp fees with your credit/debit card, please complete the following:

Card #: Name on Card:

Exp:

CVV #:

Mail registration form and check (made payable to The Cathedral Domain) to: The Cathedral Domain 800 Highway 1746, Irvine, KY 40336-8701

THE CATHEDRAL DOMAINcamp & conference center

800 Highway 1746 Irvine, KY 40336 (606) 464-8254 www.cathedraldomain.org

The episcopal diocese of lexington

Medical Release & Permisssion to treat

Date of Camp: Return completed form by: For Resident Camp Use The health history and examination must be updated annually. Health examination must be completed by a licensed medical professional. Camper's Name: Age: Home Address: City: Custodial Parent/Guardian: Home Address (if different from above): City: Contact Phone Numbers: State: Zip: home home Emergency Contact Information (if parent/guardian is unavailable) Contact Name: Relationship to Camper: Health Insurance Information ***Copy front and back of insurance card and attach to this form*** Family Physician: Family Dentist: Phone: Phone: Phone: cell cell work work State: Zip: SSN: Date of Birth: Gender: Phone: M F

The information contained in this form is not part of the camper or staff acceptance policy, but is gathered to assist in providing appropriate medical care when needed. Any changes to this form should be given to camp health personnel upon participant's arrival to camp. Complete & accurate information insures our awareness of your child's medical needs.
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Allergy Information (please list allergies and describe reactions)

Medical Release & Permisssion to treat

Is the camper allergic to any medications(s)? If yes, please list: Is the camper allergic to any food(s)? If yes, please list: Yes

Yes No

No

Are there any other allergies (ie. insect stings, environmental, etc)? If yes, please list:

Yes

No

LIST ALL MEDICATIONS (INCLUDING "OVER THE COUNTER" MEDICATIONS, VITAMINS AND/OR SUPPLEMENTS) TO BE GIVEN WHILE AT CAMP. BY LAW, ALL PRESCRIPTION MEDICATIONS MUST BE IN THEIR ORIGINAL, LABELED BOTTLES WITH THE CAMPER'S NAME, PRESCRIBER'S NAME, NAME OF MEDICATION, DOSAGE AND ADMINISTRATION INSTRUCTIONS. NO PROFESSIONAL SAMPLES WILL BE ALLOWED. Does the camper take any medication(s)? Medication: Times taken each day: Medication: Times taken each day: Medication: Times taken each day: Medication: Times taken each day: Yes No Dosage: Reason: Dosage: Reason: Dosage: Reason: Dosage: Reason:

Camper Health History Has camper had any hospitalizations, serious or chronic conditions or injuries requiring medical intervention within the past 5 years? Yes No If yes, please list: Please check any of the following which apply to camper: Bed-Wetting Asthma Seizures Infectious Disease Skin Conditions Back Problems High Blood Pressure Eating Disorder(s) Joint Pain Frequent headaches Hospitalization(s) Surgeries Please explain any checked answers:

Passing out After Exercise Heart Murmur Frequent Ear Infections Diabetes Head Injury

Page 2 of 3

Medical Release & Permisssion to treat

Has participant had mononucleosis within the past year? If female, has participant had an abnormal menstrual history? Has particpant ever had emotional issues requiring professional help? Has participant had any of the following: Measles Mumps Chicken Pox Hepatitis C Hepatitis A Hepatitis B Is participant current on all immunizations? If not, please explain: Date of last tetanus injection: Date of last TB skin test: Result: Yes No

Yes Yes Yes

No No No

Germain Measles

Mental, Emotional and Social Health History Please check all that apply: Camper has an IEP at school Camper has been treated for Attention Deficit Disorder (ADD) Camper has been treated for Attention Deficit/Hyperactivity Disorder (ADHD) Camper has been treated for emotional or behavioral difficulties Camper has been treated for eating disorders Camper has visited a professional for mental or emotional concerns Camper has been involved in a significant life altering event (history of abuse, death of a loved one, death of pet,
family change, adoption, foster care, new sibling, survived a disaster, etc.)

Is there any additional information or concerns you feel we should know?

EMERGENCY AUTHORIZATION
By signing below I acknowledge and affirm all information contained in this form is accurate and complete to the best of my knowledge. I also acknowledge the person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the staff of the Cathedral Domain to provide routine first-aid, administer prescribed medications and seek emergency medical treatment including x-rays or interventions as deemed necessary. I also grant permission to licensed medical providers selected by the Cathedral Domain to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgeries as judged appropriate for the medical situatuion. I further authorize the release of medical information to any provider, insurance company and medical facility needing such information to complete their care. I have, and do hereby, release the Cathedral Domain, its employees or agents from any and all liability associated with participation in any and all camp activities. I understand if I do not have medical insurance, I, as the participant/parent/guardian, will be responsible for any medical expenses in the event of any illness or injury. I affirm a wellness examination of the person described hereinas occurred within the last two years. I understand there are risks involved in participating in a residential camp and its activities. _________________________________________________ __________________________________________________
PRINTED NAME OF PARENT/GUARDIAN SIGNATURE OF PARENT/GUARDIAN

_________________________________
DATE

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THE CATHEDRAL DOMAINcamp & conference center

800 Highway 1746 Irvine, KY 40336 (606) 464-8254 www.cathedraldomain.org

The episcopal diocese of lexington

HEALTH CARE RECOMMENDATIONS

Camper Name: _____________________________________________________________________ Date of Examination: _______________________________

TO BE COMPLETED BY A LICENSED MEDICAL PROFESSIONAL
ACA accreditation requirements specify camper must have a wellness exam within 24 months prior to camp attendance

Height: ____________

Weight: ____________

B/P: ____________ Yes No

Is the above camper capable of participating in an active camp program?

The above camper is currently under physician's care for the following conditions: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ What treatment, if any, should be continued while at camp? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Please list medications to be administered while at camp including dosage and frequency: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Please list any medically prescribed meal plan/dietary restrictions: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Please list any known allergies: ___________________________________________________________________________________ ___________________________________________________________________________________ Please describe any limitations or restrictions to camp activities: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Is there any additional information you would like to provide to our health care staff? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
PLEASE SIGN BELOW:

_________________________________________ _________________________________________
SIGNATURE OF LICENSED MEDICAL PROFESSIONAL TITLE

_________________________________________ _________________________________________
PRINTED NAME OF LICENSED MEDICAL PROFESSIONAL DATE

THE CATHEDRAL DOMAINcamp & conference center

800 Highway 1746 Irvine, KY 40336 (606) 464-8254 www.cathedraldomain.org

The episcopal diocese of lexington

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NON-NEGOTIABLE

We ask everyone who attends Junior and Senior Conferences to sign a Non-Negotiable Agreement containing rules of behavior while at the Cathedral Domain. These rules are intended to protect you and your welfare while attending Junior and Senior Conferences. Your signature serves as your promise and commitment to abide by all rules set forth in this NonNegotiable Agreement. Violation of any rule set forth by this agreement will result in a conference with the camp Dean who will assist you in determining your continued participation in the conference.

RULES:
1. 2. 3. 4. 5. 6. 7. 8. 9. No possession or use of tobacco, tobacco products, alcohol and/or drugs (other than prescriptions). No promiscuous activity or blatant public displays of affection. No weapons of any kind. No willful destruction of Cathedral Domain property or personal property or another camper. No theft. No "raids", shaving cream, food fights or other practical jokes. No violation of determined boundries. No bullying. No electronic communication or electronic devices, excluding MP3 only devices, (ie. cell phones, iphones, Blackberrys, PDAs, etc.) 10. All clothing is to be appropriate for church camp and camp activities. Tops are to have two straps and shorts must cover your back side. 11. Follow and obey directions given by Cathedral Domain staff & councelors, Conference staff & councelors, camp Dean, Cathedral Domain Director(s) and clergy.

To insure the awareness of all parents/guardians of the rules set forth by this Non-Negotiable Agreement, parent/guardian signature is required along with partipant's signature. ________________________________________________________________________________
PARTICIPANT'S NAME

______________________________________
DATE

______________________________________
PHONE #

______________________________________
PARTICIPANT'S SIGNATURE

______________________________________
PARENT/LEGAL GUARDIAN SIGNATURE

PLEASE BRING THIS SIGNED AGREEMENT WITH YOU TO YOUR CONFERENCE

THE CATHEDRAL DOMAINcamp & conference center

800 Highway 1746 Irvine, KY 40336 (606) 464-8254 www.cathedraldomain.org

The episcopal diocese of lexington

Participant Transportation Authorization

Please complete this form and send with your child to Senior Conference registration, Sunday, June 16, 2013 OPTION 1 - PICK UP BY PARENT OR OTHER ADULT ________________________will be picking up _______________________from
AUTHORIZED ADULT NAME OF CAMPER

Senoir Conference, Saturday, June 22, 2013.

____________________________________________________________ SIGNATURE OF PARENT/LEGAL GUARDIAN _______________________________________________________________________________________________________

OPTION 2 - CAMPER TRANSPORTING SELF _____________________________ has my permission to drive him/herself home
NAME OF CAMPER

Senior Conference, Saturday, June 22, 2013 ________________________________________

SIGNATURE OF PARENT/LEGAL GUARDIAN _______________________________________________________________________________________________________

OPTION 3 - RIDING WITH FELLOW CAMPER _____________________________ has my permission to ride home from Senior
NAME OF CAMPER

Conference on Saturday, June 22, 2012 with ______________________________.

NAME OF FELLOW CAMPER

________________________________________
SIGNATURE OF PARENT/LEGAL GUARDIAN