Bay County Sheriff's Office Community Services Division. Wilderness Camp
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1 FRANK McKETHEN SHERFF Bay County Sheriff's Office Community Services Division Wilderness Camp Boys ages 12-17, residing within the boundaries of Bay County are invited to attend the 2013 Bay County Sheriffs Office Wilderness Camp. lst Boys: June 17-21, nd Boys: June 24-28, 2013 The Wilderness Camp is afive (5) daylfour (4) night stay in the woods, where the youth will be living in cabins at the Bay County Sheriffs Office campground offj.d. Nolin Road. There they will interact with camp staffconsisting ofbay County SherijJ's Office School Resource Deputies, civilian counselors and trained medical personnel to reinforce good points. The camp prides itselfon teaching positive decision making, peer mediation and proper communication skills. Some of the activities participants will be engaging in during the week are: ***Swimming***Archery Safety & Competition*** ***Gun Safety & Competition***Survival Skills*** ***Sports**Challenge COUfse***Fishing***Crafts*** Educational demonstrations are provided by the Bay County Sheriffs Office and other assisting agencies. MPORTANT NOTES: The camp is completely funded by the Bay County Sheriffs Office, therefore no expense is incurred by the parentiguardian or camper. Due to the space needed for new campers, those persons who have attended previous sessions will be allowed to register for another session, if space is available. All meals and drinks will be provided, so please DO NOT bring your own food or drink with you.
2 Each Camper should bring: toothbrush & toothpaste 2 pair long pants (jeans work best) 2 long sleeve shirts two (2) bath towels 4 pair shorts 5 pair underwear bath soap 1 swim suit shampoo 1 pair sandals/water shoes sun screen (if needed) 1 pair sneakers bug repellent deodorant small flashlight pillow, blanket, sheet prescription medications ************************************************************************ *** DO NOT BRNG*** Radios TVs Gameboys Cell phones Pagers Cameras Jewelry Money Lighters Alcohol Knives Fireworks Tobacco products or weapons of any kind fthese items are brought to camp, they will be taken from the camper, held until the endof session and returned to the parent/guardian, providing no criminal charges are pending. ************************************************************************ ALL campers will need to meet no later than: 8:00 am on Monday morning. You will be advised of the date. Front parking lot Bay County Sheriffs Office 3421 N. Hwy 77 Panama City, Florida Parents/Guardians will need to pick up campers the following Friday at the Sheriffs Office at 6:00 pm. ********************************************************************** fyou have any questions or need additional information, please contact: Deputy Tom Hedges
3 Bay County Sheriff's Office Wilderness Camp Application ********************************************************* Repeat Camper [ ] yes [] no Name of Youth Age [] male [] female Address City, State, Zip Phone Social Security Number Parent/Legal Guardian Work Phone Cell Phone / Pager # Youth nformation Any problem areas which camp staff should be aware of, Please check one. YN YN YN YN [] [] alcohol use [] [] running away [] [] fighting [] [] gang activity [] [] drug use [] [] fire setting [] [] lying [] [] present criminal charges [] [] tobacco use [] [] violent behavior [] [] defiant [] [] past criminal charges [] [] stealing [] [] skipping class [] [] threats [] [] respect for authority f yes to any or have other concerns,pleasedescribe: ~ Has the youth ever been hospitalized for drug, alcohol or emotional problems? [ ] Yes [] No. successfully complete the program? [ ] Yes [ ] No. f yes, did youth Has youth ever attempted or threatened suicide: [] yes [] no s youth currently on medication? [] Yes [ ] No. f so, what type? Allergies: Medications: Food: nsects: Other: Additional information regarding youth that may be beneficial to camp staff: (Use back if necessary)
4 Nome of Youth: BAY COUNTY SHERFF'S OFFCE "WLDERNESS CAMP" PROGRAM RELEASE& REGSTRA TON DOB: Name of Parent/Guardian: Address: City, State, Zip: Home Phone Number: Work Phone Number: Additional Emergency Contact: Name: Phone Number: As the parent/guardian of, hereby agree: 1. To give permission to participate in approved camp activities, except as authorized by doctor's orders. 2. To give the Bay County Sheriff's Office complete authority in regard to discipline matters. 3. To give the Bay County Sheriff's Office permission to transport my child. 4. To give permission for my child to be photographed and participate in public speaking activities. 5. To give the Bay County Sheriff's Office permission to search my child and/or their personal belongings for contraband, at any time, during their participation in the Wilderness Camp program. 6. To give, upon request of camper, aspirin or Tylenol for headaches. Agreed by: Date: (Signature of Parent/Legal Guardian) State of Florida, County of Bay AFFDAVT Before me personally appeared the said, who states that he/she executed the above instrument of his/her own will and accord, with full knowledge of the purpose thereof. Personally known or produced identification. Type of D &Number Sworn to and subscribed before me this day of, (Signature of Notary Public, State of Florida) (Notary Seal) (Print/Type or Stamp Commissioned Name of Notary Public)
5 Bay County Sheriff's Office "Wilderness Camp" Report of Medical History Applicant's Name: DOB: Last First Middle Has theoopucont ever ha d ( ch eck atleft 0 f eac em) y N Y N y N Allergy to Drugs Allergy to Bee Stings Jaundice Skin Disease Diabetes Rupture/Hernia Diphtheria Broken Bones Epilepsy or Seizures Ear, Nose, Throat Trouble Stomach Trouble Bleeding Tendencies Hearing Trouble Head njury Tumor, Growth, Cyst, Cancer Hay Fever Measles Trouble Sleeping Frequent Colds Mumps Frequent or Bad Dreams Pneumonia Rheumatic Fever Kidney Trouble Asthma Scarlet Fever Bowel Trouble Shortness of Breath Small Pox Bed Wetting Tuberculosis Chicken Pox Appendicitis Severe Tooth Trouble Whooping Cough Other: Eye Trouble Swollen/Painful Joints Other: Normal Check Each tem in Appropriate Column Abnormal Normal.. Check Eachterniri ~ppropriate Cplumn Abnormal 1. Head, face, neck, scalp 9. Heart 2. Nose 10. Vascular system 3. Sinuses 11. Abdomen, viscera, hernia 4. Mouth, throat, teeth 12. Anus & rectum 5. Ears, general 13. Extremities 6. Eyes, general (wears glasses) 14. Spine & Musculoskeletal 7. Pupils (equality & reaction) 15. Skin & Lymphatics 8. Lungs, chest,breasts 16. General System Allergies: Medication: nsects: Food: Other: [ ] do [] do not find the applicant fit for a strenuous camp program. The following are medical conditions or limitations to be concerned with: Physician's Name (print) Physician's Phone Number: Physician's Signature Date
6 Authorization for Medical Treatment fwe, the undersigned, as the parents and/or guardians of (please print) child's name:, hereby consent to any and all emergency medical and surgical treatments, including anesthesia and surgical procedures, which may be deemed advisable by qualified physicians selected by agents or officials ofthe Bay County Sheriff's Office. The intention thereof is to grant authority to administer and to perform examinations, treatments, anesthesia, surgical procedures and diagnostic procedures which may now, or during the course of the patient's care, be deemed advisable or necessary by qualified physicians. Physician'sName ConmctPhone# MedicalnsuranceCompany Policy # Addressof nsurancecompany Group # Student'sAddress Phone Age Parent/Guardian Social Security # Phone Business Phone Emergency Contactif Parent/Guardian cannot be reached:, Relationship Address Home Phone Business Phone s your childallergicto any form of medicationor anesthesia: [ ] Yes [ ] No, f yes describe: s your childpresentlyunder medical treatment/taking medication: [] Yes [ ] No, f yes describe: Frequency of medication Does yourreligion prohibitany specifiedmedical procedure? [ ] Yes[ ] No, f yes describe: N WTNESS of my consentand agreementto the matters stated above, have subscribedmy signaturebelow. Date: / / YY MM DD Signatureof Parent / Guardian State of Florida, County of. Swornto and subscribed before me this day of, 2013, by, who is personallyknown to me or who has produced as identification. Signature of NotaryPublic Typed, Printed or StampedName ofnotary My Commission Expires Notary Public CommissionNumber 02120/13 rjh
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