Application 2018 Montana TU Conservation and Fly Fishing Camp

Transcription

1 Application 2018 Montana TU Conservation and Fly Fishing Camp Montana Trout Unlimited invites twenty kids between ages 11 and 14 to join volunteers and professionals July 15-19, 2018 to learn about fly fishing, fly tying, watershed management, native fish and more at Camp Watanopa on the banks of Georgetown Lake. The camp includes a habitat restoration tour and field trips to area trout streams and a fish hatchery. Montana TU provides all fishing equipment and classroom supplies during the camp. Participants do not need to have prior fishing experience, just a willingness to learn! The following pages contain registration materials required to complete your application. You are welcome to mail or these forms. Please complete all blanks on these forms. If there is a blank that is not applicable, please write N/A in that blank, incomplete applications will not be considered. Campers are asked to write a short statement about why they would like to attend camp. Please include this statement with your application materials. Please return completed applications to jessica@montanatu.org before April 15, We always have more applicants than spots at camp. Applicants will be notified by May 1, 2018 if their application has been accepted. Montana Trout Unlimited will not be offering financial assistance for applicants. The camp fee of $400 must be received by May 15, Campers who are interested in attending camp but cannot afford the tuition are encouraged to contact their local Trout Unlimited to inquire whether they will be accepting applications for Montana Trout Unlimited Conservation and Fly Fishing Camp. Please feel free to reach out with questions via to jessica@montanatu.org or via phone Completed applications may also be mailed: Montana Trout Unlimited Attn: Jessica McCutcheon PO Box 7186 Missoula, MT Please be advised that you will be notified via regarding the status of your application. Please provide a valid address in your application materials.

2 Camper Info First Name Date of Birth Parent/Guardian Info First Name Mailing Address: Last Name Last Name Daytime Phone Relationship to Camper First Name Mailing Address: Evening Phone Last Name Daytime Phone Evening Phone Relationship to Camper Emergency Contact Name & Relationship to camper Phone Number List Person(s) Authorized to pick up your child, if not listed above: Person(s) NOT authorized to pick up your child: *if this person is a parent, please attach custody paperwork Additional Info: Can your child swim? Shoe size Shirt size

3 Medical Information Allergies or intolerance to food, medication, or any other substance: If an allergic reaction occurs, please list steps to relieve reaction: Chronic physical problems, pertinent psychological or development information, any special accommodations needed: Does your child take any medications? Please list medication, dosage, frequency etc. *We ask that campers keep their medications in the camp s first aid station. Please indicate if a camper must have medication on their person such as EpiPen or inhaler. Child s physician and contact information:

4 Montana TU Conservation and Fly Fishing Camp Parent/Guardian Consent I,, am the parental/legal guardian of Parent name Camper s name I hereby consent to his/her participation in the Montana TU Conservation and Fly Fishing Camp. In determining whether to allow him/her to participate, I recognize that Montana Trout Unlimited cannot be held responsible for him/her in the event of an injury while participating in the camp. I also realize that participation can involve risk of serious physical injury or death and agree, on his/her behalf, to assume risks. I agree to release and indemnify Montana Trout Unlimited, its officers, trustees, directors, employees, volunteers and agents from and against any and all claims, demands and judgment arising from injuries, damages or theft in connection with his/her participation. Boat Trip Consent: This year s camp experience may include a non-motorized boat trip on Georgetown Lake. In addition to the above general consent I specifically consent to allow the above-named camper to participate in this activity. Please circle: Yes / No *Parent/Guardian Initials Transportation: This year s camp experience will include field/fishing trips to sites away from the Camp Watanopa facility on Georgetown Lake. Participants will be transported in passenger vehicles. All drivers have cleared background checks per Trout Unlimited policy and have updated/appropriate insurance coverage for passengers. In addition to the above general consent I specifically consent to allow the above-named camper to participate in this activity. Please circle: Yes / No *Parent/Guardian Initials *Signature of parent or legal guardian Date Home Phone # Work Phone # Cell Phone #

5 Health Insurance and Waiver Form To be completed and signed by parent or guardian Participant s Last Name First Name Birth Date Age Gender: Male Female Parent or Guardian sname Name of Health Insurance Co.: Name on Policy Policy or Group Number Address City State Zip Phone ( ) PARENT/PARTICIPANT AGREEMENT: This health history is correct so far as I know, and the child named above has permission to engage in all prescribed activities except as noted, staff and volunteers of the Montana TU Fly Fishing and Conservation Camp exercise caution in the conduct of all camp activities; however, they do not assume responsibility for accidents, injury or illnesses suffered by its participants. I, as a parent or guardian of the child named above, individually and on behalf of the participant, hereby release, discharge and agree to indemnify Montana Trout Unlimited, their directors, volunteers, and employees from all liability for damage, injury or illness to the participant or their property relating to or deriving from their stay at the Montana TU Fly Fishing and Conservation Camp or participation in or travel to or from camp activities. AUTHORIZATION FOR TREATMENT: I, as parent or guardian of the child named above, hereby give permission to the medical or dental personnel selected by the camp to order X-rays, routine tests, treatment for the participant and necessary transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, order injections, anesthesia, or surgery, including hospitalization for the child named above. The completed forms may be photocopied for trips outside of the camp facility. I further acknowledge that I will be responsible for payment of all charges related to the medical or dental services provided. I also give permission to the camp director or authorized agent to administer over-the-counter medications and physician-ordered medication in cases deemed necessary by medical staff and/or the camp director. Parent Signature: Date:

6 Medical Treatment Release and Waiver Form In case of accident or serious illness, the Conservation School Director or designate will contact the child s parents or guardian using the information provided in their application form. If we are unable to reach the parent or guardian, the director is authorized to call the physician indicated and to follow his/her instructions. If it is impossible to contact the physician, the School Director may make necessary arrangements for medical treatment. I give permission for Montana TU s Conservation and Fly Fishing School s Director or designate to administer the listed over the counter medications according to boxed directions: Calamine lotion antibiotic cream Technu soap Benadryl lotion hydrogen peroxide Tylenol SPF 30 or higher sunscreen ibuprofen Child s Name Parent or Guardian Name and Signature Date PARENT/PARTICIPANT AGREEMENT: This health history is correct so far as I know, and the child named above has permission to engage in all prescribed activities except as noted, the staff of the Montana TU Conservation and Fly Fishing School exercises caution in the conduct of all school activities; however, they do no assume responsibility for accidents, injury or illnesses suffered by its participants. I, as a parent or guardian of the child named above, individually and on behalf of the participant, hereby release, discharge and agree to indemnify the Montana TU Conservation and Fly Fishing School, their directors, volunteers, and employees from all liability for damage, injury or illness to the participant or their property relating to or deriving from their stay at the Montana TU Conservation and Fly Fishing School or participation in or travel to or from the Montana Conservation and Fly Fishing School activities. AUTHORIZATION FOR TREATMENT: I, as parent or guardian of the child named above, hereby give permission to the medical or dental personnel selected by the school to order X-rays, routine tests, treatment for the participant and necessary transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, order injections, anesthesia, or surgery, including hospitalization for the child named above. The completed forms maybe photocopied for trips outside of the school facility. I further acknowledge that I will be responsible for payment of all charges related to the medical or dental services provided. I also give permission to the school nurse to administer over the counter medications and physician ordered medication in cases deemed necessary by the school medical staff and the School Director. Parent Signature: Date:

7 Camper Statement Please tell us why you want to come to trout camp!