Dallas Camper 2015 |

Camper Registration :: Dallas, TX :: 6/22 thru 6/26

Special Needs Health Center presents the Dallas 5 day Day Camp – starting Monday June 22 thru Friday June 26, 2015.

Register as a Champions Camper for an exciting fun filled week with games, programs, activities, learning experiences – and the message of the grace of Jesus.

The Village Church

3877 Walnut Hill Lane

Dallas, TX 75229 (map)

Activities include:

sports (baseball, soccer, basketball)
arts and crafts, water games
dance and music
Bible study and prayer
daily theme parties like SuperHero Day and Disney Day

Camp schedule:

Monday thru Thursday 9am to 4pm
Friday 12:30pm to 8:30pm

Camper Registration is $270.00 + $15 registration fee thru Sunday May 24. After 5/24, Registration is $310 + $15 registration fee.

Please complete and submit the Camper Registration Form below – by the week before camp starts. The form collects some information, then directs you to PayPal, where you can pay your fee via your PayPal account or with any major credit card. You will receive a confirmation email to the address in the “Best Email Address for Communication” field, as well as a confirmation from PayPal.

The form will take about 15 minutes to complete – it’s broken into 4 pages for your convenience. If you want to know in advance what information the form will ask you, see the Sample Forms page.

For your Camper’s safety, we are required to collect a lot of information. We’ll store it securely in our database. Please have your Camper’s personal and medical info ready, and the credit card information you’ll need to pay your fee. Thanks for your patience.

Champions wants every Camper to be able to attend and experience an exciting summer camp. If you have a special circumstance, please contact us before you register.

If you have a discount code, you’ll have the opportunity to enter it when you submit your registration form. A valid Discount Code will discount your fee at checkout.

Camper Registration Form - DALLAS 2015 - 6/22 thru 6/26

Items with an asterisk " * " are REQUIRED. The fields on this form may require 15 minutes to complete. Please have your personal info and medical info ready to go, and please have your credit card ready to pay your camp fee - this form's last step links to PayPal.

1 Camper Information

2 Health and Insurance Information

3 Routine Care Information

4 Policies and Releases

ROUTINE CARE INFORMATION

Please answer the following questions honestly and thoroughly so we can best respond to your Camper’s needs. The more we know about your Camper’s routine, the better our staff can assist them. Items with an asterisk " * " are REQUIRED
Is your Camper verbal, or non-verbal?*
- Verbal
- Non-verbal
If your Camper is non-verbal, please detail the method of communication he /she uses:
Does your Camper need assistance with any activities on this list?*
Click inside the box to show the list of activities your Camper may need assistance with. Select an activity to add it to the list. Repeat to add multiple choices. Select "x" to delete an activity.
Please explain how your Camper will need assistance with the indicated activity or activities:
Has your Camper ever received treatment or medication for psychiatric or behavior disorders?*
- No
- Yes
Please detail your Camper's behavior, and any treatment or medication for psychiatric or behavior disorders your Camper has ever received:
Does your Camper have any negative behaviors we might experience?*
- No
- Yes
Please list/detail any negative behaviors we might experience and explain the best way to deal with them.
Does your Camper have any special routines it would be helpful for the Camp Staff to know about?*
- No
- Yes
Please detail any routines would be helpful for the Camp Staff to know about:
Please detail any additional information that would help the Champions Staff:
Please include special care instructions, or other information (examples might be: feeding tubes, catheters/PICC lines, suctioning, or other care details) ...

POLICIES; HEALTH RELEASE; MEDIA RELEASE

Please carefully read each statement below. You'll be asked to initial each section using your mouse or touch screen, and to sign and date the document before you Submit. Signatures and items with an asterisk " * " are REQUIRED
Medication at Camp

Prior to camp, you will receive a medication form. You will be able to provide specific details on how and when to administer medication. The policy regarding medication is as follows: • Keep all medication in its original pharmacy labeled bottle or its original over-the-counter packaging. The medical staff will not dispense any medications not in its original container. This policy includes vitamins and herbs. • Place medication bottle or original over-the-counter package in a labeled Ziploc bag. • Include the medication form in the Ziploc bag with the medication needed for the week. • Bring your medication with the form on the first day of camp.
Special Information or Medical Needs

To help give the best care for your child, please provide detailed written instructions for any special medical needs beyond the information you provided on the Online form. If there is special information or routines for your child that absolutely must be adhered to, please contact our office at 913-638-6823 to discuss prior to the Event. We will make every effort to accommodate each child, but we need appropriate time for setting up special requests.
Special Diets

If your child requires a special diet beyond the information you provided on the Online form, please detail this in a statement and attach it. You will be required to bring your own food for lunch and snacks daily.
Behavior Issues

Children with a diagnosed behavior related disorder will be treated with care and respect as with all campers. All behavior issues at camp are dealt with in the following manner: • At first offense, the camper will discuss his or her behavior with their group staff leader and with their camp buddy. The three will discuss alternative behaviors that are appropriate. • At second offense, the camper, group staff leader and camp buddy will discuss the offense with the Camp Director and appropriate consequences will be initiated, such as withholding a favorite activity for one activity period. • At third offense, the camper, group staff leader and camp buddy will report to the Camp Director for discussion and appropriate consequences will be initiated. (This is equivalent to being sent to the school principal.) Special Needs Health Center will send the child home if it is deemed that the child is being a danger to self or others. Discipline is done through discussion and redirecting. It is a last resort to send a child home. • In no situation are physical measures utilized for consequences. Absolutely no spanking, slapping or other physical contact is ever used by anyone at camp for discipline.
Behavior Disorders

The camper with a diagnosed behavior disorder will always be treated with measures that are safe and respectful for the camper’s best interest. However, if the child has an outburst that causes danger to self or others, more stringent methods of control will be initiated. In all situations involving a “meltdown,” the first steps taken are assisting the child to regain control through calm talking and giving the child space. If after several minutes these methods do not produce a safe demeanor in the child, the next step is assessing the situation and removing the child from the group. Parents are notified of unacceptable behavior.
Phone Usage

Campers are not allowed to use phones during camp hours. Most campers do well at camp, but calling home can initiate a wave of homesickness.
Medical Emergencies

If a medical emergency occurs, parents or guardians will be notified as soon as possible. If a situation requires that a camper be taken to a hospital emergency room, the hospital staff will often contact the parent for information. Every effort will be made to contact the parent or guardian prior to the emergency staff contacting you. It is your responsibility to provide the necessary contact information while your child is at camp.
Cancellations

If your child will not be able to attend the event in which they are enrolled, you must notify Special Needs Health Center immediately.
Policies - Initial*
I have carefully read and understand the above Special Needs Health Center Inc. policies. I agree with the policies and will inform my camper of the rules and policies of camp. (Initial with your mouse or touchscreen.)
Release of Liability - Initial*
I understand that Special Needs Health Center Inc. is NOT responsible for loss of clothing or personal property while at events. I agree to bring all articles of clothing and personal property clearly marked with my first and last name. I understand that part of the day camp experience involves activities, group social arrangements and interactions. These activities and interactions may come with certain risks or uncertainties, and I am aware of these risks. I realize that no environment is risk-free, and I understand risks are minimized when following the rules as instructed by the camp staff. These rules are made to insure safety for all and I agree to follow all rules. I hereby, and for my heirs, executors, and administrators, assigns and all legal guardians, waive and release any and all rights and claims of any nature I may have against Special Needs Health Center Inc., its directors, collectively and individually, employees, Board of Directors, coaches, campers and cooperating entities for and against any and all injuries and damages of any nature, including death, which I may suffer while taking part in Special Needs Health Center Inc. Day Camp or other activities associated with Special Needs Health Center Inc. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE Special Needs Health Center, INC., RELEASE OF LIABILITIES. (Initial using your mouse or touchscreen.)
Medical Authorization and Privacy Agreement - Initial*
I hereby give permission to the physician selected by the Camp Director to order routine medical tests, X-rays, and treatment for emergency health concerns in the event that the parent/guardian cannot be reached. I give the members of the camp medical team permission to administer over-the-counter medications as needed and to give scheduled medication as ordered on the Medication Instruction Form. I realize the camp has a limited liability medical policy for volunteers with a $2,500 maximum limit, covering only trauma, not illness. Any medical expenses in excess of this amount will be my responsibility. I authorize any physician, nurse or other health care provider to communicate with the camp medical staff and any Director of Special Needs Health Center, or his/her designee, concerning my medical condition, treatment and/or prognosis. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE Special Needs Health Center, INC., MEDICAL AUTHORIZATION AND PRIVACY AGREEMENT. (Initial using your mouse or touchscreen.)
Media Release - Initial*
I realize that photographs and films of camp activities may be taken and used for fund-raising and publicity purposes. I hereby give my consent to Special Needs Health Center Inc., its officers, employees, agents, chapters, assignees, licensees and cooperating entities, to use my picture, name, portrait, likeness, writings or biographical information, and/or audio tape for editorial, educational, promotional and advertising purposes, for the solicitation of contributions and for any other purposes in furtherance of the corporate purposes and objectives of Special Needs Health Center, Inc. This release and consent shall be binding upon my child’s heirs, executors, administrator, assigns, and all legal guardians of my child. I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH THE Special Needs Health Center, INC., MEDIA RELEASE. (Initial using your mouse or touchscreen.)
Full Signature*
I HAVE CAREFULLY READ, UNDERSTAND AND AGREE WITH ALL POLICIES AND STATEMENTS IN THIS Special Needs Health Center, INC., CAMPER REGISTRATION FORM. (Add your signature below with your mouse or touchscreen.)
Today's Date*
(Legal Signature requires you to pick today's date...)
Pay your Camper fee below.

If Champions sent you a Discount Code, enter it below when prompted. Only some Campers receive a Discount Code. Selecting "Submit" completes this form and links you to PayPal, where you can pay with your PayPal account or any credit card. Valid Discount Codes will subtract from the Camp fee at PayPal checkout.
Do you have a Discount Code?
- No
- Yes
Enter your Discount Code:
A valid Discount Code will discount your total fee at PayPal Checkout.
$20 Discount Code*
Price: -$20.00
$50 Discount Code*
Price: -$50.00
$75 Discount Code*
Price: -$75.00
$100 Discount Code*
Price: -$100.00
$150 Discount Code*
Price: -$150.00
$175 Discount Code*
Price: -$175.00
$200 Discount Code*
Price: -$200.00
$225 Discount Code*
Price: -$225.00
Camper Registration - Dallas Camp 2015 (Mon. 6/22 thru Fri. 6/26)
Camper Registration is $270.00 + $15 registration fee thru Sunday, May 24. [After 5/24, Registration will be $310 + $15 registration fee.] If you enter a valid Discount Code, we'll discount your total fee at PayPal Checkout.

Price: $285.00
Total
$0.00
Thanks. You are about to submit your Registration form...

When you select "Submit your Registration Form, and pay with PayPal", Champions will store your Registration information in our secure database. You will then arrive at PayPal, where you can (a) pay your fee with any credit card, or (b) select " Cancel and Return to Champions" to exit PayPal without paying. Use that Cancel and Return test link if you have already paid your fee, or if you intend to pay Champions at a later time using the Donate page on our web site. See you at Camp!!

Dallas Camper 2015

Camper Registration Form - DALLAS 2015 - 6/22 thru 6/26

CAMPER INFORMATION:

HEALTH AND INSURANCE INFORMATION:

ROUTINE CARE INFORMATION

POLICIES; HEALTH RELEASE; MEDIA RELEASE

Medication at Camp

Special Information or Medical Needs

Special Diets

Behavior Issues

Behavior Disorders

Phone Usage

Medical Emergencies

Cancellations

Pay your Camper fee below.

Thanks. You are about to submit your Registration form...