Alcohol, drugs, tobacco, bad language and inappropriate pictures/books/magazines are prohibited at all times. Each camper is under the leadership of, and subject to the directions given by the group leaders/counselors at all times during the trip. Campers will not damage anyone else’s property. Property damage, either intentionally or unintentionally, will be paid for by the person or persons responsible. All members of the trip are expected to conduct themselves in such a manner as not to bring discredit upon themselves, the group, or the church. All campers are expected to follow the dress code. Campers not complying will be asked to change clothes. If at any time during camp an adult asks a camper to change clothes, they should do so immediately without question or complaint. At no time will a camper leave the camp grounds without an adult. The camper will attend all scheduled sessions. Campers will not leave their cabins after lights out. Boys are not allowed in the girls’ cabins at any time, and girls are not allowed in the boys’ cabins at any time. Cell phones, iPods, MP3 players, CD players, hand-held games, etc., will be allowed only on the trip to and from Camp Como. These items cannot be used at any time during the week of camp and will be confiscated if used. It’s best to leave them at home. Any confiscated items will be returned on Thursday. If campers are unable to abide by the rules stated above, they will be sent home immediately at their parents/guardian’s expense. This consequence is completely at our discretion and may be deemed necessary due to behavioral misconduct, violation of the dress code or leaving the cabin after lights out, etc. My signature certifies that I am willing to abide by the rules and regulations outlined in the ‘Camp Como Rules.’ My parents and I understand that breaking any of the above rules and regulations will result in me being sent home immediately at the expense of my family. Camper Signature________________________________ Date_________ Parent Signature_________________________________ Date_________

What should we bring to Camp Como? PACKING LIST

(Arrive at Rocky at 1:30 pm on July 13)

If you have any questions, please do not hesitate to contact Marie Dudrey at 303-652-6894.

� Water Bottle—VERY important!

� Bible

� Notebook, Pen/Pencil

� Clothes for 4 Days plus an extra outfit (dress code attached, shorts must clear fingertips)

� Toiletries

� Towels/Washcloths

� Light jacket/Rain Jacket or Poncho

� Tennis shoes

� Hiking shoes (if you have them)

� Pillow and Twin Bedding or Sleeping Bag

� Sunscreen

� UV Protective Lip Balm

� Sunglasses

� Flashlight

� Canteen/General Store $$ (you will be able to purchase snacks, Gatorade, Propel and Como souvenirs)

DO NOT BRING SNACKS FOR YOUR CABIN. . .

Rev. 1/14

PHYSICAL EXAMINATION FORM

Physical Examination (Doctor or CNP to complete)

Camper’s Name: ____________________________________ Birth Date: ______________ Camp Dates: _____________________

I have examined this person within the past 24 months and found him/her capable of active participation in a regular camp program except as follows:

__________________________________________________________________________________________________________

List any known Allergies: ____________________________________________________________________________________

__________________________________________________________________________________________________________

Medication(s) which camper must take: (include prescription & non-prescription).

Medication Dosage Frequency Reason for taking Physician

Date of Last Physical Exam: ____________________________

Date of Immunizations (or attach copy of immunization record): *

Vaccination: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr

DPT

Polio

Measles

Mumps

Rubella

Hepatitis B

Date of Last Tetanus Booster

*We do accept campers that are non-immunized; we will need a signed waiver from a parent or guardian for exemption.

Signature of Physician or CNP: _____________________________________________

Date: ____________Address: ______________________________________________________Phone: ____________________

Social Service Regulation: In addition to current parent/ guardian provided health history, Camp Como must have a

statement confirming a physical examination has been performed within the preceding 24 months by a Doctor or Licensed

Nurse Practitioner. Also, Camp Como MUST have CURRENT WRITTEN authorization from the Health Care Provider

for any required prescription or non-prescriptive medicines. You may use the form below or send a copy of a current

physical examination including immunization dates.

MEDICATIONS BROUGHT TO CAMP MUST BE IN ORIGINAL LABELED CONTAINER(S).

COLORADO LAW REQUIRES THAT THIS FORM BE COMPLETED FOR EACH STUDENT ATTENDING COLORADO SCHOOLS

Name_________________________________________________________________ Date of Birth _______________________________________

Parent/Guardian __________________________________________________________________________________________________________

COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT—CERTIFICATE OF IMMUNIZATION

Vaccine Enter the month, day and year each immunization was given

Hep B Hepatitis B

DTaP Diphtheria, Tetanus, Pertussis (pediatric)

DT Diphtheria, Tetanus (pediatric)

Tdap Tetanus, Diphtheria, Pertussis

Td Tetanus, Diphtheria

Hib Haemophilus influenzae type b

IPV/OPV Polio

PCV Pneumococcal Conjugate

MMR Measles, Mumps, Rubella

Varicella ChickenpoxHealthcare Provider

Documentation Date _________________________________ Lab Verification Date_________________________________

Vaccines recorded below this line are recommended. Recording of dates is encouraged.

HPV Human Papillomavirus

Rota Rotavirus

MCV4/MPSV4 Meningococcal

Hep A Hepatitis A

TIV/LAIV Influenza

Other

IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE.SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LES PONGA EN CUARENTENA O SE LES EXCLUYA DE LA ESCUELA.

MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medicallycontraindicated due to other medical conditions.EXENCIÓN POR RAZONES MÉDICAS: El estado de salud de la persona arriba citada es tal que la vacunación significa un riesgo para su salud o incluso su vida; obien, las vacunas están contraindicadas debido a otros problemas de salud.

Medical exemption to the following vaccine(s):La exención por razones médicas aplica a la(s) siguiente(s) vacuna(s):

Signed (Firma) _________________________________ Date (Fecha) ____________ � � � � � � � �Physician (Médico) Hep B DTaP Tdap Hib IPV PCV MMR VAR

RELIGIOUS EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposedto immunizations.EXENCIÓN POR MOTIVOS RELIGIOSOS: El padre o tutor de la persona arriba citada, o la persona misma, pertenece a una religión que se opone a la inmunización.

Religious exemption to the following vaccine(s):Exención por motivos religiosos de la(s) siguiente(s) vacuna(s):

Signed (Firma) _________________________________ Date (Fecha) ____________ � � � � � � � �Parent, guardian, emancipated student/consenting minor Hep B DTaP Tdap Hib IPV PCV MMR VAR

(Padre, tutor, estudiante emancipado o consentimiento del menor)

PERSONAL EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposedto immunizations.EXENCIÓN POR CREENCIAS PERSONALES: Las creencias personales del padre o tutor de la persona arriba citada, o la persona misma, se oponen a lainmunización.

Personal exemption to the following vaccine(s):Exención por creencias personales de la(s) siguiente(s) vacuna(s):

Signed (Firma) _________________________________ Date (Fecha) ____________ � � � � � � � �Parent, guardian, emancipated student/consenting minor Hep B DTaP Tdap Hib IPV PCV MMR VAR

(Padre, tutor, estudiante emancipado o consentimiento del menor)

STATEMENT OF EXEMPTION TO IMMUNIZATION LAW (DECLARACIÓN RESPECTO A LAS EXENCIONES DE LA LEY DE VACUNACIÓN)

CDPHE-IMM CI RC Rev. 2/12

THIS SECTION CAN BE COMPLETED BY CHILD CARE/SCHOOL/HEALTH CARE PROVIDER

� A) Child Care Up to Date ______________________________________________________________Up to date through 6 months of age for Colorado School Immunization Requirements Update Signature Date

� B) Child Care Up to Date ______________________________________________________________Up to date through 18 months of age for Colorado School Immunization Requirements Update Signature Date

� C) Child Care/Pre-school/Pre-K* ______________________________________________________________Up to date for Child Care/Pre-School/Pre-K for Colorado School Immunization Requirements Update Signature Date

� D) Complete for K–5th Grade ______________________________________________________________Up to date for K–5th Grade for Colorado School Immunization Requirements Update Signature Date

* If age 4 years and fulfills Requirements for Pre-School & Kindergarten, check BOTH Boxes C and D.

HAS MET ALL IMMUNIZATION REQUIREMENTS FOR COLORADO SCHOOLS (6TH GRADE OR HIGHER)

Signed ____________________________________________ Title _____________________________________ Date________________________(Physician, nurse, or school health authority)

Table 2. TIMETABLE FOR IMPLEMENTATION OF REQUIREMENTS FOR SELECTED IMMUNIZATIONS FOR GRADES K TO 12

Refer to Table 1 for the minimum number of doses required for a particular grade level. Table 2 shows the year of implementation for a requirement fromTable 1 and is restricted to varicella vaccine dose 1 (Var1) and dose 2 (Var2) and tetanus, diphtheria, and pertussis vaccine (Tdap). Requirements andeffective dates for other vaccines are listed in Table 1. In this table, after a vaccine is required for grades K to 12, it is no longer shown, but therequirements listed in Table 1 continue to apply.

School YearGrade Level

K 1 2 3 4 5 6 7 8 9 10 11 12

2007–08 Var2 Var1 Var1 Var1 Var1 Var1TdapVar1

Var1 Tdap

2008–09 Var2 Var2 Var1 Var1 Var1 Var1TdapVar1

TdapVar1

Var1 Tdap Tdap

2009–10 Var2 Var2 Var2 Var1 Var1 Var1TdapVar1

TdapVar1

TdapVar1

Var1 Tdap Tdap Tdap

2010–11 Var2 Var2 Var2 Var2 Var1 Var1TdapVar1

TdapVar1

TdapVar1

TdapVar1

TdapVar1

Tdap Tdap

2011–12 Var2 Var2 Var2 Var2 Var2 Var1 Var1 Var1 Var1 Var1 Var1 Var1

2012–13 (Var1 requiredfor grades K to 12)

Var2 Var2 Var2 Var2 Var2 Var2 Var1 Var1 Var1 Var1 Var1 Var1 Var1

2013–14 Var2 Var2 Var2 Var2 Var2 Var2 Var2

2014–15 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2

2015–16 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2

2016–17 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2

2017–18 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2

2018–19 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2

2019–20 (Var2 requiredfor grades K to 12)

Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2 Var2

Table 1. MINIMUM NUMBER OF DOSES REQUIRED FOR CERTIFICATE OF IMMUNIZATION

a: Vaccine doses administered no more than 4 daysbefore the minimum interval or age are to becounted as valid.

b: Five doses of pertussis, tetanus, and diphtheriavaccines are required at school entry in Coloradounless the 4th dose was given at 48 months of ageor older (i.e., on or after the 4th birthday) in whichcase only 4 doses are required. There must be atleast 4 weeks between dose 1 and dose 2, at least4 weeks between dose 2 and dose 3, at least 6months between dose 3 and dose 4 and at least 6months between dose 4 and dose 5. The final dosemust be given no sooner than 4 years of age (dose4 may be given at 12 months of age provided thereis at least 6 months between dose 3 and dose 4). Ifa child has received 6 doses of DTaP before theage of 4 years, no additional doses are required.

c: For students 7 years of age or older who havenot had the required number of pertussis doses, nonew or additional doses are required. Any student 7years of age or older at school entry in Coloradowho has not completed a primary series of 3 appro-priately spaced doses of tetanus and diphtheria vac-cine may be certified after the 3rd dose of tetanusand diphtheria vaccine (or tetanus, diphtheria, andpertussis vaccine if 10 or 11 years) if it is given 6months or more after the 2nd dose.

d: The student must meet the minimum priorrequirement for the 4th or 5th doses of diphtheria,tetanus, and pertussis vaccine and have 1 tetanus,diphtheria, and pertussis vaccine dose.

e: For polio, in lieu of immunization, written evi-dence of a laboratory test showing immunity isacceptable.

f: Four doses of polio vaccine are required at schoolentry in Colorado unless the 3rd dose was given at48 months of age or older (i.e., on or after the 4thbirthday) in which case only 3 doses are required.There must be at least 4 weeks between dose 1 anddose 2, at least 4 weeks between dose 2 and dose3 and at least 6 months between dose 3 and dose4. The final dose must be given no sooner than 4years of age. Minimum age/interval does not apply if4th dose of polio (3rd dose if given after 4th birth-day) was administered prior to July 1, 2009.

g: For measles, mumps, and rubella, in lieu ofimmunization, written evidence of a laboratory testshowing immunity is acceptable for the specific dis-ease tested. The 1st dose of measles, mumps, andrubella vaccine must have been administered at 12months of age or older (i.e., on or after the 1st birth-day) to be acceptable.

h: The 2nd dose of measles vaccine or measles,mumps, and rubella vaccine must have been admin-istered at least 28 calendar days after the 1st dose.

i: Measles, mumps, and rubella vaccine is not requiredfor college students born before January 1, 1957.

j: The number of Hib vaccine doses requireddepends on the student’s current age and the agewhen the vaccine was administered. If any dose wasgiven at 15 months of age or older, the Hib vaccine

requirement is met. For students who began theseries before 12 months of age, 3 doses arerequired of which at least 1 dose must have beenadministered at 12 months of age or older (i.e., on orafter the 1st birthday). If the 1st dose was given at12 to 14 months of age, 2 doses are required. If thecurrent age is 5 years of age or older, no new oradditional doses are required.

k: The number of pneumococcal conjugate vaccine(PCV) doses required depends on the student’s cur-rent age and the age when the 1st dose was admin-istered. If the 1st dose was administered before 6months of age, the child is required to receive 3doses 2 months apart and an additional dosebetween 12–15 months of age. If started between7–11 months of age, the child is required to receive2 doses, two months apart and an additional dosebetween 12–15 months of age. For any student whoreceived the 3rd dose on or after the first birthday, a4th dose is not required. If the 1st dose was given at12 to 23 months of age, 2 doses are required. If anydose was given at 24 months of age through 4years of age, the PCV vaccine requirement is met. Ifthe current age is 5 years or older, no new or addi-tional doses are required.

l: For hepatitis B, in lieu of immunization, written evi-dence of a laboratory test showing immunity isacceptable. The second dose is to be administeredat least 4 weeks after the first dose, and the thirddose is to be administered at least 16 weeks afterthe first dose and at least 8 weeks after the second

dose. The final dose is to be administered at 24weeks of age (6 months of age) or older and is notto be administered prior to 6 months of age. Mini-mum age/interval does not apply to those studentswho had 3 doses of the vaccine administered priorto July 1, 2009.

m: For varicella, written evidence of a laboratorytest showing immunity or a documented diseasehistory from a health care provider is acceptable.The 1st dose of varicella vaccine must have beenadministered at 12 months of age or older (i.e., onor after the 1st birthday) to be acceptable.

n: If the second dose of varicella vaccine wasadministered to a child before 13 years of age, theminimum interval between dose 1 and dose 2 isthree months, however, if the second dose is admin-istered at least 28 days following the first dose, thesecond dose does not need to be repeated. For achild who is 13 years of age or older, the seconddose of varicella vaccine must have been adminis-tered at least 28 calendar days after the 1st dose.See Table 2 for the school years/grade levels thatthe 1st and 2nd doses of varicella will be required.

o: Information concerning meningococcal diseaseand the meningococcal vaccine shall be provided toeach new student or if the student is under 18years, to the student’s parent or guardian. If the stu-dent does not obtain a vaccine, a signature must beobtained from the student or if the student is under18 years, the student’s parent or guardian indicatingthat the information was reviewed

VACCINE a

Level of School/Age of Student

Child Care2–3 mos

Child Care4–5 mos

Child Care6–7 mos

Child Care8–11 mos

Child Care12–14 mos

Child Care15–18 mos

Child Care19–23 mos

Pre-school2–4 yrs

K Entry 4–6 yrs

Grades K to 5

5–10 yrs

Grades 6 to 12

11–18+yrsCollege

Hepatitis B l 1 2 3 3 3 3

Pertussis/ Tetanus/Diphtheria

1 2 3see

footnote b4 5/4 b 5/4 b c 5/6 c d

Haemophilusinfluenzae type b (Hib) j

1 2 2 3/2 3/2 3/2/1 3/2/1 3/2/1

PneumococcalConjugate k

1 2 3/2 4/3/2 see footnote k

Polio e 1 2 3 4/3 f 4/3 f 4/3 f

Measles/ Mumps/Rubella g

1 see footnote g 2 h 2 h 2 h 2 h i

Varicella m 1 see footnote n 2 n 2/1 n 2/1 n

Meningococcal o