Fossil rim wildlife center

Fossil Rim Wildlife Center
Ph: 254-897-2960, Fax Number: 254-898-4091 PLEASE FILL OUT A FORM FOR EACH CHILD.
CHILD INFORMATION

LAST NAME___________________FIRST NAME_________________ AGE ____ DOB _______M/F___

PARENT INFORMATION
LAST NAME _____________________________ FIRST NAME ______________________________
Relationship to Child _______________________ Primary Contact Number _____________________

Applying for Scholarship ___YES ____NO
Siblings attending ____YES ____NO Other Relatives/Friends Attending _____Yes _____No
Name(s):____________________________________________________________________________
Summer Camp 2012
Session 1 $250.00
Session 5 $250.00
“Wild at Work” Ages 11-17 (June 8-10)
“It Matters to Me”” Ages 11-17 (July 20-22)
Session 2 $250.00
Session 6 $90.00

“It Matters to Me” Ages 11-17 (June 15 - 17)
“It Matters to Me” Ages 7-10 (July 28)
Session 3 $90.00
Session 7 $90.00
““It Matters to Me” Ages 7-10 (June 30)
“It Matters to Me” Ages 7-10 (August 4)
 Session 4
“Wild at Work” Ages 11-17 (July 13-15)

Discounts for Siblings or Multiple Sessions:
Initial Camp: First child pays full price. Siblings receive a 10% discount.
Additional Camp Sessions: All participants receive a 10% discount
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Payment Information:

Credit Card Payments: Billing will occur approximately 14 days prior to camp.
Check Payments: Payment by check is due no later than 21 days prior to the event or the
camp reservation will be cancelled. Check(s) will be deposited upon receipt no sooner than 21
days prior to camp date, and no later than 14 days prior to camp date.
DONATIONS – Fossil Rim Wolf Ridge Summer Camp operates on the premise that our
programs, facilities, and staff are an effective way to teach children how to be stewards of our planet. If you
share this vision, then please consider donating of your time, talents, gifts, and service. In addition, Fossil Rim
Wildlife Center invites organizations to partner with youth who wish to attend camp and who face hardship in
paying the full tuition.
Yes! I believe in teaching children the importance in being good stewards of our Earth and its inhabitants. I
want to respond with a gift of:
$25______ $50______ $75 ______ $100 ______ other $________
II would like to donate a full scholarship for a child to attend camp in the amount of:
$75 Day Camp______

Sponsorship of a family or group camp $____________

_____ PLEASE BILL MY CREDIT CARD ON FILE FOR THE ABOVE DONATION AMOUNT.
_____PLEASE CONTACT ME FOR DONATION INFORMATION.
Scholarship Information:
Scholarships will be awarded based on financial need and/or merit. If you would like to be considered 
for a scholarship, please complete the following section:
a. Below $10,000 b. $10,000 to $18,000 c. $18,000 to $25,000 d. $25,000 to $32,000 e. $32,000 to $40,000 f. Above $40,000 Number of adults _____ children _____ in household. Why do you need a scholarship? _________________________________________________________________________________ _________________________________________________________________________________  _________________________________________________________________________________ Dates will attend camp: from ___________________to________________ Camper Name: _________________________________________________________________________ Developed and reviewed by: American Camp Association, Birth Date: ____________ Age on arrival at camp: ________ American Academy of Pediatrics Council on School Health, & To Parent(s)/Guardian(s): Please follow the instructions below.
ATTN: Education Department
Attach additional needed information.
Fossil Rim Wildlife Center
2155 County Road 2008
1) Complete all pages of this form and make a copy.
Glen Rose, TX 76043
2) Mail this signed form to the address below by (date)
Camper Home Address: _________________________________________________________________________________________________________________________ Parent/guardian with legal custody to be contacted in case of illness or injury: Name: ____________________________ to Camper: ________________ Preferred Phones: (______) ________________ (______)_________________ Email: ___________________________________________ Home Address: ______________________________________________________________________________________________________________________________ (If different from above) Street Address Second parent/guardian or other emergency contact: Name: ____________________________ to Camper: ________________ Preferred Phones: (______) ________________ (______)_________________ Email: ___________________________________________ Additional contact in event parent(s)/guardian(s) can not be reached: Name: ____________________________ to Camper: ________________ Preferred Phones: (______) ________________ (______)_________________ Email: ___________________________________________
Allergies: □ No known allergies □ This camper is allergic to:
□ Food □ Medicine □ The environment (insect stings, hay fever, etc.) □ Other (Please describe below what the camper is allergic to and the reaction seen.)
_________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Diet, Nutrition: □ This camper eats a regular diet. □ This camper eats a regular vegetarian diet. □ This camper has special food needs.
(Please describe below.)
_________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Camp Activities Restrictions: □ I feel the camper can participate in camp activities without restrictions.
□ I feel the camper can participate in camp activities with the following restrictions or adaptations. (Please describe below.)
_________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Medical Insurance Information:
This camper is covered by family medical/hospital insurance: □ Yes □ No *Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company______________________________ Policy Number___________________________ Subscriber_____________________________________ Insurance Company Phone Number (______) ___________________ Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician and/or paramedics selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician and/or paramedics to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
_____  INITIAL HERE (Parent / Guardian)

If for religious or other reasons you cannot initial this, contact the camp manager at (254)897-2960
Copyright
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Camper Name: _______________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses The following non-prescription medications may be stocked in the Infirmary and are used on an as needed basis to manage illness and injury. Cross out the medications that the camper (should not) be given:
ications that the camper (should not) be given:
Phenylephrine decongestant (Sudafed PE) Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Medication: □ This camper will not take any daily medications while attending camp.
□ This camper will take the following daily medication(s) while at camp:
"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies.
We require original pharmacy containers with labels which show the camper’s name and how the medication should be given. Provide enough of each medication to last the
entire time the camper will be at camp. (Medication cannot be shared between siblings. They must have their prescription.)
Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization forms
from health-care providers or state or local government are an acceptable alternative; please attach to this form. Month/Year Month/Year Month/Year Month/Year If your camper has not been fully immunized, please acknowledge your understanding of the following statement by signing below:
I understand and accept the risks to my child from not being fully immunized.
_____  INITIAL HERE (Parent / Guardian)
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Camper Name: _______________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses General Health History: Check "Yes" or "No" for each statement. Explain “Yes” answers below.
1. Ever been hospitalized? …………………………. □ Yes □ No 11. Had fainting or dizziness? . □ Yes □ No 2. Ever had surgery? . …………. □ Yes □ No 12. Passed out/had chest pain during exercise? ….……………. ………… □ Yes □ No 3. Have recurrent/chronic illnesses? .……….… □ Yes □ No 13. Had mononucleosis ("mono") during the past 12 months?. □ Yes □ No 4. Had a recent infectious disease? . …………. □ Yes □ No 14. If female, have problems with periods/menstruation?.……. …………. □ Yes □ No 5. Had a recent injury? . …………. □ Yes □ No 15. Have problems with falling asleep/sleepwalking? . □ Yes □ No 6. Had asthma/wheezing/shortness of breath?. □ Yes □ No 16. Ever had back/joint problems?…….……….……………. □ Yes □ No 7. Have diabetes? . …………. □ Yes □ No 17. Have a history of bedwetting?………………….……………. □ Yes □ No 18. Have problems with diarrhea/constipation?……………………………… □ Yes □ No 9. Had headaches? …………………………………. □ Yes □ No 19. Have any skin problems?……………………. □ Yes □ No 10. Wear glasses, contacts, or protective eyewear? □ Yes No 20. Traveled outside the country in the past 9 months?. □ Yes □ No Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel.
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Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ……………………………… □ Yes 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……. □ Yes □ No 3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….…………………………………. □ Yes □ No 4. Had a significant life event that continues to affect the camper’s life?. □ Yes □ No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information. Answering yes to these questions will
not disqualify your child from attending. _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Health-Care Providers:
Name of camper’s primary doctor(s): ____________________________________________________ Phone: (________) ________________________ Name of dentist(s):___________________________________________________________________ Phone: (________) ________________________ Name of orthodontist(s):_______________________________________________________________ Phone: (________) ________________________ What Have We Forgotten to Ask?
Please provide in the space below any additional information about the camper’s health that you think important or
that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.
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Inc. Page 5 of 7
Camper Name: _______________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses A. Medical Consent, Liability Release, and Waiver:
I, the parent / guardian of the child mentioned in page 1 of this document, give my permission for Fossil Rim Wildlife Center Staff permission to take the necessary steps
to ensure the health and safety of my child; including but not limited to the administration of first aid, CPR, and / or transportation of the said minor to the nearest hospital
or clinic for medical treatment.
_____  INITIAL HERE (Parent / Guardian)

I, the parent / guardian of the child mentioned in page 1 of this document, have indicated on page 2 which over-the-counter medications my child can and cannot take. I
am giving Fossil Rim’s staff permission to administer these medications according to my selections on an as-needed basis.
_____  INITIAL HERE (Parent / Guardian)

B. Social Network Disclaimer
I agree to refrain from negative, derogatory, slanderous, or reputation damaging practices, aimed towards the detriment of Fossil Rim Wildlife Center, due to any social
networking activity including but not limited to blogging, Facebook, MySpace, and/or Twitter.
_____  INITIAL HERE (Parent / Guardian)
C. Photo / Video Release
By initialing, I understand that at this event or related activities, I may be photographed. I hereby consent to allow my photo, video, or film likeness to be used for any
legitimate purpose, including but not limited to marketing, advertising, and/or social networking by the event holders, producers, sponsors, organizers and assigns. The
photos will not be used for any purpose other than the stated purpose. Not all photos will be used; only those deemed most advantageous for the purpose intended and
that most accurately depict the subject matter.
_____  INITIAL HERE (Parent / Guardian)

D. Camp Information
Fossil Rim Wildlife Center’s overnight and day camps are designed to provide an opportunity to learn about our conservation efforts. Because a major part of the camp
experience will involve interacting with all aspects of nature, including animals, we ask that campers behave in a responsible and cooperative manner at all times. We
are confident that each participant will have an educational and fulfilling experience; however, those who find it difficult to be kind and respectful will be asked to sit out,
and if necessary, removed from camp. No refund will be provided if a participant is removed from camp due to inappropriate behavior.
_____  INITIAL HERE (Parent / Guardian)

I acknowledge that camp is an outdoor activity in which my child will participate at their own risk. I acknowledge that they will be walking and riding in vehicles on rough
uneven terrain through wildlife inhabited wilderness. I understand that they will need to follow all of Fossil Rim Wildlife Center rules and regulations for all activities and
understand that I am fully responsible for my child’s actions. I release and forever discharge Fossil Rim Wildlife Center, its employees, agents, members, sponsors,
promoters, and affiliates from any and all liability claim, cost, or expense, and waive any such claims against any such person or organization, arising directly from any
such activity in which my child may participate during camp. Further, I agree to participate in AMA approved mediation regarding any disputes arising from this activity.
My child currently has no physical or mental condition that would impair their capability for full participation as intended and expected.
_____  INITIAL HERE (Parent / Guardian)
I, as a parent / guardian of the participant mentioned in page 1 of this document, represent to Fossil Rim Wildlife Center that the facts herein concerning my child or ward
are true. I hereby give my permission for my child or ward to participate in camp activities and events. Further, in consideration granting such license, agree, individually
and on the behalf of my child or ward, to the terms of the above agreement and release of liability.
_____  INITIAL HERE (Parent / Guardian)
E. General Accident Waiver and Release of Liability
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING AND/OR VOLUNTEERING IN THIS ACTIVITY OR EVENT, including by way of example and not
limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or
property owned, maintained or controlled by Fossil Rim Wildlife Center or High Hope Ranch, or because of their possible liability without fault. I acknowledge that this
Accident Waiver and Release of Liability document will be used by the event holders, sponsors, and organizers of the activity or event in which I or my child might
participate, and that it will govern my actions and responsibilities at the said activity or event. I WAIVE, RELEASE, AND DISCHARGE FROM ANY AND ALL
LIABILITY, including but not limited to , liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property
damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event. THE FOLLOWING ENTITIES OR
PERSONS: Earth Promise dba Fossil Rim Wildlife Center, High Hope Ranch, and/or their directors, officers, employees, volunteers, representatives, and agents, the
activity or event holders, activity or event sponsors, and/or activity or event volunteers.
_____  INITIAL HERE (Parent / Guardian)
I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND THE CONTENT THEREIN. I AM AWARE THAT THIS IS A RELEASE OF
LIABILITY AND A CONTRACT THAT I AM SIGNING OF MY OWN FREE WILL. THIS CONTRACT STANDS ALONE AND IS NOT CONTINGENT UPON ANY
OTHER SPOKEN OR WRITTEN INSTRUMENT.
Print Participant’s name: ___________________________________________
Participant’s Signature: ____________________________________________ *Parent/Guardian must sign if participant is under age 18 Parent/Guardian Signature: ________________________________________ Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep
a copy for your records
Copyright 2008 by American Camping Association, Inc.  Page 6 of 7
Camper Name: _______________________________________________________ Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses
Individual Health Record (For Camp Use Only)
Initial Screening:
Date/Time:_________
Initials: ____________
Screening has been conducted according to camp protocol and significant findings noted as follows: A. Any signs/symptoms of illness or injury upon arrival?. □ No □ Yes as noted below B. History of exposure to communicable disease?. □ No □ Yes as noted below C. Additions or corrections to information on this health history?. □ No □ Yes as noted below D. Medication turned in to health-care staff?. □ No □ Yes as noted below E. Any signs/symptoms of head lice?. □ No □ Yes as noted below
Provider notes: (date/time/initial all entries) ___________________________________________________________________
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□ Left camp this day with no reported illness or injury symptoms. □ Left camp this day with the following problem/concern: ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ This person was told about the problem and instructed about follow-up as noted above: (Name)______________________________ Date/Time: ___________ Initials: __________ Copyright Inc. Page 7 of 7

Source: http://www.fossilrimwildlifecenter.us/SC_2012_Application.pdf