2015 INFORMATION  

WHERE: JUMONVILLE RETEAT CENTER 887 Jumonville Road Hopwood, PA 15445 WHEN: SUNDAY, AUGUST 2- FRIDAY, AUGUST 7, 2015

ARRIVAL SUNDAY, AUGUST 2, 2015

2:00-4:00pm

DEPARTURE SUNDAY, AUGUST 2- FRIDAY, AUGUST 7, 2015

6:00pm Closing ceremonies

GIRLS AGES 7-17

REGISTRATION FEE: $150.00 CHECKS PAYABLE TO: Pitcairn Camp “G”

ABSOLUTELY NO REFUNDS WILL BE GIVEN!

PHYSICALS The Commonwealth of Pennsylvania requires campers

to have a physical examination. Please have your family physician complete and sign the attached forms.

CAMP REGISTRATION DATE: JUNE 11, 2015

WHERE: St. Paul’s Church 416 Center Avenue Pitcairn, PA 15140 *Next to Propel School

WHEN: 5:30-7:30pm

QUESTIONS? Maureen Hartin

412.600.1366 Dona Galia

412.380.4681

Emergency Phone #:

724-439-4912

REGISTER EARLY CAMP SPACE IS LIMITED THIS YEAR!

Counselor applications must be received by July 1st. Late registrations will not guarantee counselor status!

                   NAME: ___________________________________________________________________________________ FIRST MIDDLE LAST

ADDRESS: ________________________________________________________________________________

CITY: __________________________________ STATE: ___________ ZIPCODE: ______________________

AGE AT CAMP: ___________ BIRTHDATE: ______/______/______

CAMPER’S CELLPHONE: _____________________________________

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN: ______________________________________________________________________

CELL PHONE: _______________________________ WORK PHONE: ______________________________

PARENT/GUARDIAN: ______________________________________________________________________

CELL PHONE: _______________________________ WORK PHONE: ______________________________

EMERGENCY CONTACT

NAME: _________________________________________ RELATIONSHIP TO: ________________________

PHONE # _______________________________________

*Pitcairn Camp “G” does not discriminate against any child due to race, color, creed or nationality.

* Pitcairn Camp “G” does retain the right to reject any camper registration for valid reasons!

* Pitcairn Camp “G” reserves the right to send any camp/counselor home due to disciplinary

problems or rule violation!

*ALL PITCAIRN CAMP “G” ACTIVE MEMBERS HAVE COMPLETED THE PENNSYLVANIA STATE

CRIMINAL RECORD CHECK, CHILD ABUSE HISTORY CLEARANCE AND FBI CLEARANCE.

           

2015 CAMPER REGISTRATION

FOR STAFF USE ONLY DATE RECEIVED: ____________________ CHECK #: _____________ AMT. ___________ CASH $: ______________ OTHER: _______________

RECEIVE EMAILS TO STAY INFORMED ABOUT Pitcairn Camp “G”

Email:___________________________________

_

 

SMALL MEDIUM LARGE X-LARGE XX-LARGE

YOUTH

ADULT

T-SHIRT SIZE

CAMPER NAME: ______________________________________________

FIRST YEAR CAMPER REQUEST FORM

1st YEAR CAMPER REQUEST:_________________________________________ We will honor the request of “First Year Campers” in assigning a sister and/or friend to the same cabin.

IF YOUR CHILD HAS ATTENDED CAMP, PLEASE DO NOT ASK! YOUR CAMPER’S NAME: ____________________________________________ AGE: ___________    

         

Once again Pitcairn Camp “G” will have in force a ZERO TOLERANCE POLICY

that is applicable to ALL counselors and campers during camp week.

ZERO TOLERANCE MEANS:

ABSOLUTELY NO OFFENSIVE LANGUAGE WILL BE TOLERATED!

ABSOLUTELY NO OFFENSIVE BEHAVIOR WILL BE TOLERATED!

ABSOLUTELY NO BEHAVIOR THAT THE OFFICERS FEEL MAY BE DEEMED HARMFUL TO ANY CAMPER/COUNSELOR OR STAFF MEMBER WILL BE

TOLERATED!

If you are found in violation of this policy or any other camper/counselor rules you will receive a penalty from the officers. The officers will determine the severity of the penalty which may include expulsion from camp and/or camp in the future. Pitcairn Camp “G” strives to provide a fun-filled week for all campers/counselors. If you comply with this policy as well as the other camper/counselor rules, you will enable us to have a great week at camp! Camper’s Signature: _______________________________________________ Parent/Guardian’s Signature: _______________________________________ Date: ____________________________

2015 ZERO TOLERANCE POLICY  

PHOTO RELEASE

As the parent/guardian of a child attending Pitcairn Camp “G” you know that our primary objective is to provide a fun-filled week of camp activities for your child. With your acknowledgment, we want to share our successes with staff, local school, administrators and the public. Occasionally, events occur at Camp “G” that are of interest to the public. Because of public interest in these events, members of the press, including photographers, may be in attendance. In an effort to highlight the positive efforts of our camp and staff, we would like your permission to capture images of your child or use photos of your child interacting with staff, parents and/or other children. The images will not be used in any form of paid advertising, but may appear on the Pitcairn Camp “G’s” or another organization’s website or social media pages. Please complete and sign the form below and return with your registration. If you have any questions regarding this matter, please feel free to call Pitcairn Camp “G” President, Maureen Hartin at 412.600.1366. My child, _____________________________________________, has permission to be photographed and/or videoed. My child, _____________________________________________, does not have permission to be photographed and/or videoed. Parent/Guardian’s Signature: ___________________________________________________________ Date: ___________________________

PHOTO RELEASE  

Family Code of Conduct One of the goals of Pitcairn Camp “G” is to provide families of campers and counselors with an environment that encourages courtesy and mutual respect for each child, family member/guardian represented in the program and Pitcairn Camp “G” staff that work together to implement this goal. It is understood by this Family Code of Conduct that any family member/guardian who is in violation will be asked to leave camp immediately and afterwards will not be permitted to return to Pitcairn Camp “G.” The staff and members of Pitcairn Camp “G” ask that families adhere to the following standards. ∗ Inappropriate Language

o Family members/guardians/designated caregiver represented will refrain from using inappropriate language at any time, directly or indirectly, with Camp “G” staff, other adults or in the presence of children while at Pitcairn Camp “G.’

∗ Threats o The safety of our children, families and staff are important to us. Therefore, threats will not be

tolerated under any circumstances and will be reported to proper authorities. ∗ Confidentiality

o Any and all personal information on our children, families and staff are considered confidential and are not to be shared. ONLY photos of your child and Pitcairn Camp “G” staff (with permission) may be taken for the purpose of your family’s memoir.

∗ Social Media/Technology o Photos, videos or comments relating to Pitcairn Camp “G” staff, program or children/families

will not be permitted. ∗ Corporal Punishment

o No physical or verbal punishment at Pitcairn Camp “G” I understand that by violating any item on this Family Code of Conduct, my child’s attendance at Pitcairn Camp “G” will be terminated immediately and she will not be permitted to return in the future. It is my responsibility to notify all family members or temporary caregivers whom may accompany my child or children to Pitcairn Camp “G” of the contents of this policy and procedure. *I have read and understood the above information. Should I choose not to provide my signature below I must abide by this Family Code of Conduct Policy and corresponding procedure. _______________________________________ _______________________________________ __________________ Parent/Guardian Signature Date _______________________________________ _______________________________________ __________________ Pitcairn Camp G Officer Signature Date PROCEDURE: When a violation of the Family Code of Conduct is observed the following procedure will be followed. 1. Staff/family will contact the Camp Director and Camp “G” President immediately after the incident occurs. 2. When a determination that a violation of this policy has occurred, the President of Camp G or designee will contact the family to inform them of the outcome.

FAMILY CODE OF CONDUCT  

   NAME: ___________________________________________________________________________________ FIRST MIDDLE LAST

PARENT/GUARDIAN-Please answer the following questions.

Is your child in good health? YES or NO ALLERGIES: Does your child have allergies? YES or NO ALLERGY: ___________________________ REACTION: ______________________________________ ALLERGY: ___________________________ REACTION: ______________________________________ ALLERGY: ___________________________ REACTION: ______________________________________ Does your child suffer from? (Please Circle) Diabetes Heart Disease Cancer Seizure Disorder Asthma

Stomach Problems Mental Disorder Social Disorder Pulmonary Disorder

If you circled any of the above, please give a brief explanation to include your child’s diagnosis, medication and any special needs while at camp: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Is your child at a high risk for any of the following? (Please Circle) Sunburn Poison Ivy/Oak Sore Throat Stomach Cramps

Homesickness Bedwetting

Does your child have any physical or sensory limitations? (Please Circle)

Poor Eye Sight Sprain, Strain or fracture to any extremities

Hearing Loss Other: ___________________________

MEDICATION:

Will your child need to take medications while attending camp? YES or NO (If yes, please have the physician list them on the physical examination page.)

Please list any condition that will limit your child from participating in any activity while at camp: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________    

2015 MEDICAL & PHYSICAL FORM

       

NAME: ___________________________________________________________

MUST BE COMPLETED BY A CERTIFIED PHYSICIAN ONLY! The child listed above will be attending a weeklong camp consisting of physical activities (swimming, sports, etc.) Please give this child a physical examination. List any abnormalities or special needs that the camp medical staff should be made aware of to provide proper care and treatment. HEIGHT: __________________ WEIGHT: __________________ BLOOD PRESSURE: __________________  CIRCLE IF ABNORMAL: Growth Development Ears Nose Neck

Muscular Skeletal Teeth Tonsils Skin

Thyroid Lungs Head Eyes

Genitalia G.I. Glands Hernia

Other: _____________________________________________________ Explanation of abnormality: ______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Diet or Activity Restrictions: _______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ MEDICATIONS NAME DOSAGE FREQUENCY ____________________________ / ____________________________ /____________________________ ____________________________ / ____________________________ /____________________________ ____________________________ / ____________________________ /____________________________ Physician’s Signature x___________________________________________ Date: ______________ Physician’s Name: ___________________________________________________________ Address: ____________________________________________________________________ Telephone #: ____________________________

PHYSICAL EXAMINATION