2013 HUGS Camp HELPER Registration - Amazon S3

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					                      The Episcopal Diocese of North Carolina

       2013 HUGS Camp HELPER Registration
Camp dates: July 7-13, 2013
Tuition: $390 (1/3 due with registration)
Helpers must be 14 years old by August 31, 2013.
Download form. Complete ALL information on computer then print and sign.
Official acceptance will be mailed to you within 2 weeks of receipt of application.
Make checks payable to: The Episcopal Diocese of NC
Mail completed forms to: Beth Crow, 200 W. Morgan St., Suite 300, Raleigh, NC 27601
Please submit registrations as soon as you are able since we can only accept Campers when we have Helpers.
Thank you.

Name ______________________________________                          Goes by ___________________
Gender: Male ___ Female ___           Birthdate ____________ Age ____       2012-13 School Grade ______

Address _____________________________________________________________________________
City ____________________________________________________ State ____ Zip Code __________

T-Shirt Size (Adult sizes): XS ____    S ____   M ____     L ____    XL ____    XXL _____

Church ___________________________________________ City ______________________________

E-mail address for at least one parent/guardian AND the helper are required for communication.
Helper e-mail ________________________________________________________________________
Father e-mail ________________________________________________________________________
Mother e-mail________________________________________________________________________
Guardian e-mail ______________________________________________________________________

Father _____________________________________________                   Home (____)_______________
                           Work (____)_______________                   Cell (____)_______________

Mother _____________________________________________                    Home (____)_______________
                          Work (____)_______________                    Cell (____)_______________

Guardian _____________________________________________                   Home (____)_______________
                          Work (____)_______________                     Cell (____)_______________

Insurance Information Please mail a copy with your registration.
Company ____________________________________________________________________________
Subscriber number ____________________________________________________________________

Why I want to be a HUGS Camp Helper ____________________________________________________
                                   Health Information

Health History

                             Yes    No                                          Yes    No
Asthma                                     If “Yes”, uses an inhaler?
Diabetes                                   If “Yes”, uses insulin?
Other health conditions                    If “Yes”, list below
Surgery in past year                       If “Yes”, list below
Physical restrictions                      If “Yes”, list below

Date of last Tetnus __________

Other health conditions


Physical restrictions

Vision: Normal _____         Glasses _____     Contacts _____
Hearing: Normal _____        Hearing Aid _____

Diet: Regular _____       Diabetic _____  Gluten Free _____
      Vegetarian _____    Vegan _____
      Other _________________________________________

The included health history is correct to my knowledge, and the helper camper described herein has
my permission to engage in all camp activities, except as noted. In the event that I cannot be reached
in an emergency, I hereby give permission for my child, named above, to secure proper treatment as
deemed necessary by the camp nurse, and may include: transport, hospitalization, medications, X-ray,
routine tests, anesthesia, or surgery for the person named above.

_______________________________________________________________                 __________________
Signature of Parent/Guardian                                                       Date
                                     Signature Sheet
                             Signatures are REQUIRED for ALL items below

Attendance/Release Permission
I hereby give permission for my child, named above, to attend HUGS Camp.
The Episcopal Diocese of North Carolina and HUGS Camp have my permission to use photographs,
slides, and video footage of the above named participant in camp promotions and newsletters.
    Yes _____ No_____

_____________________________________________________________                   __________________
Signature of Parent/Guardian                                                         Date

Personal Assistance Permission
We have read the camp description in “Parental Permission for Helper Campers,” and
understand that my child will be acting as an assistant to those who are unable to do for
themselves. This may include feeding, dressing, toileting, and/or bathing. I have discussed this with my
child, and we are aware of and comfortable with their expected responsibilities at HUGS Camp.

_____________________________________________________________                   __________________
Signature of Parent/Guardian                                                         Date

_____________________________________________________________                   __________________
Signature of Helper Camper                                                           Date

Cross-Gender Assistance Permission
In making assignments, we do everything possible to pair campers and helper campers of the same
However, there are instances where the numbers are not equal and we are not able to do this. When a
cross-gender assignment is necessary, the camper will have minimal needs and will not require
physical assistance with toileting or bathing from their helper camper, but will require guidance and
 All helper campers are expected to be enthusiastic participants with the campers, regardless of their
 After discussing and accepting the responsibilities entailed, indicate your permission below:

    I permit my child to assist a camper of the opposite gender. Yes _____             No _____

_____________________________________________________________                   __________________
Signature of Parent/Guardian                                                         Date

_____________________________________________________________                   __________________
Signature of Helper Camper                                                           Date

Scholarship requests/Financial Assistance
_____ I am NOT requesting a scholarship and will pay the full tuition amount.
_____ I am requesting a scholarship for financial assistance AND
       _____AND I have completed and am submitting the “Scholarship Application” form.
       _____AND I understand that 1/3 of the tuition will be provided by The Episcopal Diocese of NC.
       _____AND I understand that I am responsible for 2/3 the tuition, and will make arrangements
                   for payment by my church/sponsor. Any balance not paid is due by registration.

_____________________________________________________________                   __________________
Signature of Parent/Guardian                                                         Date
                HUGS Camp Medication Form 2013
Name ____________________________________________
Allergies ____________________________________________________________________
______ Takes no routine medications
          Medication                       Dosage                            Administration Times

                                                                                   10:00 am

                                                             7:30 am

                                                                                                      3:00 pm

          Treatment                       Body Area                                              Times
                                                               7:30                1:00           Bed Other
                                                               am                  pm             time

Special Foods                                Breakfast Lunch                       Snack              Dinner

Over-the-Counter Medications that may be taken if needed
                Yes    No                         Yes   No                                                Yes             No
Tylenol                     Motrin                           Peptobismol
Tums                        Benadryl (for                    Allergy meds
                            allergic reactions)
Cough drops                 Sunscreen                        Bug Spray
Mineral Oil                 Senna                            Colace
Antibiotic                  Benadryl
ointment                    ointment

_____________________________________________________________                                                   __________________
Signature of Parent/Guardian                                                                                         Date

_____________________________________________________________                                                   __________________
Signature of Nurse at Camp                                                                                           Date
Bowel Program                                                  Name _____________________________
    Regular bowel movements are necessary to keep a person healthy and feeling good. Unfortunately, when
people are away from home, constipation becomes a problem. We realize that not everyone has a bowel
movement every day, however at camp it can become a problem, even for those already on a bowel program, for
several reasons: I. Different food; 2. Different routines; and 3. Little privacy.
    We want camp to be a pleasant and fun place. In order to do this, we need to make sure that constipation
does not get to the point where the person is uncomfortable, so we are going to start a routine bowel program.
    At dinner, the nurses will privately ask each helper and camper whether they had a bowel movement that day.
If they have not, they will be put on the bowel program until they have a bowel movement.

The program is:
       Day 1: 1 TBS mineral oil at breakfast the next day
       Day 2: 1 TBS mineral oil at bedtime and at breakfast the next day
       Day 3: 1 TBS mineral oil and 1 tablet Senna at bedtime, 1 TBS mineral oil at breakfast
                if no BM by lunch the next day repeat Senna at dinner.
       Day 4: Call parent/guardian to discuss options

       Mineral oil is a lubricant only, it has not laxative effects.
       Senna is a natural fiber based gentle laxative.

I have read the above bowel program and give my permission for it to be used with my child.
        Yes _____ No _____

_____________________________________________________________                         __________________
Signature of Parent/Guardian                                                               Date

_____________________________________________________________                         __________________
Signature of Nurse at Camp                                                                 Date

HUGS Camp Community Covenant For Helpers
It is not acceptable for members of The HUGS Camp Community to:
 1. Engage in sexual conduct, contact, or behavior;
 2. Use, possess, or be under the influence of tobacco, alcohol, or illegal or non-prescribed drugs;
 3. Commit acts of theft or violence;
 4. Enter the sleeping areas of the opposite gender
 5. Possess or use fireworks, firearms, or weapons of any sort, including pocket knives;
 6. Show disrespect to fellow campers, staff, property of others, or property of The Summit;
 7. Leave the established boundaries without the permission of the Camp Director;
 8. Fail to obey the established camp schedule and norms or fail to remain with their group during
This is a Community Covenant, and a violation of this covenant is a violation of the community. All
violations will be dealt with appropriately by HUGS Camp staff. Possible consequences may include
notification of the violator's parents and/or rector, and the violator may be asked to leave HUGS Camp

I have read, understand, and agree to abide by the covenant:

_____________________________________________________________                         __________________
Signature of Helper Camper                                                                 Date

I have read and understand this covenant:

_____________________________________________________________                         __________________
Signature of Parent/Guardian                                                               Date

HUGS campers come in all sizes, shapes, races, and ability levels. They represent a variety of socio-
economic levels, cultures, and faiths. From honor students and athletes, to Down’s Syndrome
individuals, to total care campers, they come together to celebrate God’s gifts of life, love, and diversity.

Each year we are typically blessed by the presence of several total care campers. Despite their gifts
and personalities, these individuals are so incapacitated by cerebral palsy, brain injury, or other
conditions that they are not able to feed, dress, bathe, or toilet themselves. In such cases, their needs
are addressed by camp staff and by helper campers who are comfortable with these tasks.

Sometimes cross-gender assistance can be helpful in toileting or bathing a total care camper. This
usually means that strong arms and backs are needed to lift large, heavy, or awkward total care
campers. Such cross-gender assistance is permitted only with prior consent from parents of the helper
campers and the special needs campers who are involved…and only when it is necessary to give
adequate support to the special needs camper. In such cases, a member of the same gender will also
be present.

Before the special needs campers arrive, the helper campers and staff receive training and practice in
many care-giving activities and strategies such as:
         leading a blind person and helping that person with dining room procedures.
         lifting and moving a quadriplegic from a bed to a wheelchair and back, from a wheelchair to a
       chair and back, from a wheelchair to a toilet and back, and from a wheelchair into the pool and
       back, etc.
         navigating/controlling wheelchairs on camp terrain, & up and down ramps.
         feeding those who can not feed themselves.
         using sign language to communicate basic information.
         dealing with seizures.

Campers and staff are then given in-depth information about the mental and physical abilities and
disabilities of the individual special needs campers. Information about personalities, likes and dislikes,
behaviors, etc. are also shared to the extent that they are known.

Helper campers and staff discuss this information along with personal concerns, comfort levels,
abilities, and preferences. Then the helper campers decide which special needs camper they would
most like to assist.
Through a period of negotiating, helper campers are paired with special needs campers the day before
the special needs campers arrive. Two or more partners are assigned to total care campers, and one or
more partner(s) is/are assigned to the more capable campers.

As parents, it is important for you to understand what your child may or may not be expected to do as a
helper camper. Therefore, we ask that you please indicate whether or not your child has your
permission to assist with the more strenuous and more personal tasks of caring for special needs
campers. Giving your permission does not mean that your child will be required to give assistance in
toileting, etc. It simply means that your child has permission if he or she wishes to take on that

Please discuss this with your child. Then, complete and return the form on the back so that we
understand your wishes in this matter. THANK YOU!

Please sign the “Personal Assistance Permission” on the signature sheet. Do not return this

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