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100 Years of inspiring girls & young women - Girl Scouts in the Heart ...

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GIRL SCOUT TRADITIONS<br />

<strong>100</strong> <strong>Years</strong> <strong>of</strong> <strong><strong>in</strong>spir<strong>in</strong>g</strong> <strong>girls</strong> & <strong>young</strong> <strong>women</strong><br />

September 21 - 23, 2012<br />

Camp Furnace Hills, Denver, PA<br />

WHO IS ELIGIBLE TO ATTEND? The Adult Volunteer Weekend is open to ALL registered adult<br />

<strong>Girl</strong> <strong>Scouts</strong>. (No tag-a-longs please, only registered adults). We <strong>in</strong>vite you to plan far ahead and<br />

attend this fabulous weekend getaway filled with volunteer led workshops that range from adult<br />

enrichment sessions, to learn<strong>in</strong>g how to do activities with your <strong>girls</strong>. Visit with o<strong>the</strong>r <strong>Girl</strong> <strong>Scouts</strong><br />

and get ideas on what <strong>the</strong>y do with <strong>the</strong>ir <strong>girls</strong> or just relax!<br />

WHERE: Camp Furnace Hills, 1610 <strong>Girl</strong> Scout Road, Denver, PA. Camp Furnace Hills is<br />

located <strong>in</strong> nor<strong>the</strong>astern Lancaster County. Camp Furnace Hills is adjacent to <strong>the</strong> Middlecreek<br />

Wildlife Preserve with easy access to <strong>the</strong> Horseshoe Trail. Accommodations range from <strong>the</strong><br />

modern Foxfire Program Center to rustic cab<strong>in</strong>s and platform tents. Outdoor cook<strong>in</strong>g facilities<br />

are available at all sites. The 19th century banke house located on <strong>the</strong> property is on <strong>the</strong><br />

National Registry <strong>of</strong> Historic Places and home to <strong>the</strong> Foxfire Program.<br />

REGISTRATION FEES:<br />

**Weekend Registration Fee is $30.00. (Includes lodg<strong>in</strong>g; all meals (Friday supper, Saturday breakfast,<br />

lunch, supper and Sunday breakfast) and Weekend T-shirt)<br />

**Saturday Only Registration Fee is $15.00. (Includes Saturday meals and Weekend-T-shirt)<br />

**Additional fees for some <strong>of</strong> <strong>the</strong> workshops. (See Workshop Descriptions) Non-refundable.<br />

HOW TO REGISTER:<br />

**Complete all sections <strong>of</strong> pages 6-9 and return with payment to:<br />

Cris Christ<br />

224 W. Sheridan Avenue<br />

Annville, PA 17003<br />

**Make Checks Payable to: GSHPA - P<strong>in</strong>e Mounta<strong>in</strong> Service Unit 703<br />

**Incomplete registrations will be returned delay<strong>in</strong>g confirmation.<br />

Please Note: If you would like to come for <strong>the</strong> day on Saturday to do <strong>the</strong> Tra<strong>in</strong><strong>in</strong>g courses or Fun<br />

Workshops you can attend for $15.00 (<strong>in</strong>cludes meals & T-shirt). If <strong>the</strong>re is a cost for <strong>the</strong> Tra<strong>in</strong><strong>in</strong>g<br />

Courses or Fun Workshops you are tak<strong>in</strong>g that cost is extra.<br />

Example: If you are com<strong>in</strong>g on Saturday to do <strong>the</strong> First Aid and CPR Class <strong>the</strong> cost is $40.00 You would pay <strong>the</strong><br />

$40.00 for <strong>the</strong> Class and $15.00 for Saturday registration = $55.00.<br />

If you would like to attend on Saturday for <strong>the</strong> Tra<strong>in</strong><strong>in</strong>g Courses or Fun Workshops without meals & T-<br />

shirt you can attend and pay only <strong>the</strong> cost <strong>of</strong> <strong>the</strong> Course or Workshop.<br />

**Rem<strong>in</strong>der -- you MUST mail <strong>in</strong> a registration form even if you are only com<strong>in</strong>g Saturday!!!<br />

CONFIRMATION:<br />

A confirmation packet, with assigned sessions, camp list, directions to camp and a map <strong>of</strong><br />

Camp Furnace Hills will be e-mailed (mailed if requested) 2 weeks prior to <strong>the</strong> Volunteer<br />

Weekend.<br />

-1-


ARRIVAL/DEPARTURE TIMES:<br />

*Weekenders: Please arrive between 4:30 pm and 10:00 pm, Friday even<strong>in</strong>g and check-<strong>in</strong> at<br />

Holly Hall.<br />

*Saturday only: Please arrive between 6:30 am and 8:30 am, Saturday morn<strong>in</strong>g and check-<strong>in</strong><br />

at Holly Hall.<br />

ACCOMMODATIONS:<br />

Please <strong>in</strong>dicate on your registration form if you need a lower bunk or o<strong>the</strong>r special<br />

accommodations. All requests are handled on a first-come basis, so please send your request<br />

<strong>in</strong> early!!!<br />

REGISTRATION DEADLINE: Friday, August 31st, 2012<br />

**EARLY BIRD REGISTRATION -- 10% <strong>of</strong>f <strong>the</strong> $30.00 and entered <strong>in</strong> a special draw<strong>in</strong>g for<br />

register<strong>in</strong>g early. Early bird registration deadl<strong>in</strong>e July 13, 2012.<br />

WORKSHOP SESSIONS:<br />

Complete session descriptions are found on <strong>the</strong> follow<strong>in</strong>g pages. Please fill out your "Workshop<br />

Choices" on <strong>the</strong> Registration Form. If you do not list a second, third or fourth choice and your<br />

first choice is full, you will be assigned free time!<br />

EVENTS:<br />

The weekend schedule is jam-packed with workshops and activities for those <strong>of</strong> you who like to<br />

keep busy; however, you do NOT have to participate <strong>in</strong> all <strong>the</strong> <strong>the</strong>m! If you want to relax and<br />

enjoy Camp Furnace Hills, work on your own crafts, play board games, socialize, etc., you are<br />

free to do so!<br />

ANY QUESTION PLEASE CONTACT ONE OF THE FOLLOWING COMMITTEE MEMBERS:<br />

**Cris Christ (717-867-4889) e-mail -- crissychrist@aol.com<br />

**C<strong>in</strong>dy Levengood (717-884-3643) e-mail -- clevengood@gshpa.org<br />

**Barb Showers (717-865-4120) e-mail -- barbsh@comcast.net<br />

ADULT VOLUNTEER WEEKEND<br />

GIRL SCOUT TRADITIONS<br />

2012 Workshop Session Descriptions<br />

Workshops fill quickly, so register early!<br />

SATURDAY --<br />

1SAM -- FIRST AID & CPR -- (8:30 am-12:30 pm)(Carole Wagner)<br />

A <strong>Girl</strong> Scout first aider is an adult who has taken and is current <strong>in</strong> <strong>Girl</strong> Scout Council approved<br />

first aid and CPR (for adult and child). A <strong>Girl</strong> Scout first aider is needed anytime a troop/<br />

group travel away from <strong>the</strong>ir normal meet<strong>in</strong>g location. NOTE: All travel trips/camp<strong>in</strong>g trips<br />

MUST have a first aider <strong>in</strong> attendance. (m<strong>in</strong>. 6; max. 10)(cost $40.00)<br />

-2-


2SAM -- NO-SEW FLEECE BLANKET OR SCARF -- (9:00 am-10:30 am)(Mary Noel (Gus) Stenberg)<br />

Craft<strong>in</strong>g a blanket or scarf without sew<strong>in</strong>g <strong>of</strong> any k<strong>in</strong>d makes <strong>the</strong> No-Sew Fleece Blanket or<br />

Scarf a unique gift and a perfect service project. One <strong>of</strong> <strong>the</strong> charms <strong>of</strong> <strong>the</strong> blanket is that it can<br />

be tailor made to your personal <strong>in</strong>terest, favorite team or specific hobby. Best <strong>of</strong> all, this warm<br />

and cozy wrap comes with <strong>the</strong> car<strong>in</strong>g qualities <strong>of</strong> a handmade gift. A No-Sew Scarf is a fun<br />

craft project that can generally be completed <strong>in</strong> an hour or less. These scarves also make great<br />

handmade gifts for birthdays and o<strong>the</strong>r special occasions. Both No-Sew projects are great for<br />

ALL age levels! Items you should br<strong>in</strong>g: For blanket -- a sharp pair <strong>of</strong> scissors and 2 yards<br />

each, pr<strong>in</strong>t and pla<strong>in</strong> fleece material (size for teen or adult); For scarf -- a sharp pair <strong>of</strong> scissors;<br />

8" to 12" length <strong>of</strong> 58/60" wide fleece (different ends, so you might want to make two or three)<br />

and a pair <strong>of</strong> th<strong>in</strong> tweezers.<br />

3SAM -- TRADITIONAL SNACKS & FIRESIDE DESSERTS -- (9:00-11:30 am)(Brenda Oliver, Kim<br />

Carbaugh, Diana Vituszynski & Mary Neauman) I don't know about you, but, out <strong>of</strong> all <strong>the</strong> activities we<br />

did <strong>in</strong> <strong>Girl</strong> <strong>Scouts</strong>, <strong>the</strong> memories <strong>of</strong> <strong>the</strong> traditional <strong>Girl</strong> Scout recipes have stayed with me <strong>the</strong><br />

most. Remember G.O.R.P. (Good Old Rais<strong>in</strong>s and Peanuts (a term for trail mix <strong>of</strong>ten used by hikers)), ants<br />

on a log, peanut butter balls, just to name a few we enjoyed at meet<strong>in</strong>gs and events. How<br />

about cook<strong>in</strong>g over a campfire or us<strong>in</strong>g a dutch oven, buddy burner or box oven! Everyone<br />

knows <strong>of</strong> <strong>the</strong> traditional s'more (that toasted, melted, burned, dropped <strong>in</strong> ash and wiped <strong>of</strong>f marshmallow treat<br />

loved by kids <strong>of</strong> ALL ages.) But, <strong>the</strong>re are so many more traditional <strong>Girl</strong> Scout recipes that you can<br />

share with your <strong>girls</strong>. Come and have some fun learn<strong>in</strong>g & tast<strong>in</strong>g some great traditional<br />

recipes and broaden your cul<strong>in</strong>ary delights. (cost $7.00)<br />

4SAM -- SCRAPBOOKING -- (9:00-11:00 am)(Casey Christ) Have some fun<br />

scrapbook<strong>in</strong>g and learn some skills to cont<strong>in</strong>ue <strong>the</strong> hobby or teach your<br />

troop. Make a 12"x12" memory sheet, learn to make cards and gifts tags.<br />

Assorted sheets will be available along with stickers and embellishments.<br />

Items you should br<strong>in</strong>g: 3-5 photos for your memory sheet and a sharp scissors.<br />

(max. 8)(cost $8.00)<br />

5SAM -- SIT-UPONS/DUNK BAGS & S.W.A.P.S -- (9:00-11:00 am)(Gail Daub) If you know what<br />

a "sit upon" is you must have been a <strong>Girl</strong> Scout. Come and make your own sit-upon (homemade,<br />

usually waterpro<strong>of</strong> pads used to protect <strong>the</strong> user's backside from <strong>the</strong> cold & damp while "sitt<strong>in</strong>g upon" <strong>the</strong> ground.),<br />

dunk bag (a mesh bag that conta<strong>in</strong>s everyth<strong>in</strong>g necessary for eat<strong>in</strong>g at <strong>Girl</strong> Scout camp. <strong>Girl</strong>s enjoy mak<strong>in</strong>g<br />

someth<strong>in</strong>g that is useful and needed <strong>in</strong> order for <strong>the</strong>m to take a camp<strong>in</strong>g trip) and 5 traditional camp<strong>in</strong>g<br />

S.W.A.P.S. (Some Whatchamacallit Affectionately P<strong>in</strong>ned Somewhere). All great <strong>Girl</strong> Scout traditions!!<br />

Item you should br<strong>in</strong>g: hole punch (if you have one). (cost $4.00)<br />

6SAM -- MACRAMÉ WORKSHOP -- (9:00-11:30 am)(G<strong>in</strong>ny John) Learn to make assorted<br />

macramé <strong>in</strong>clud<strong>in</strong>g necklaces, bracelets, bookmarks, key cha<strong>in</strong>s and small ornaments.<br />

(cost -- Price range $2-$10, depend<strong>in</strong>g on item. Pay <strong>in</strong>structor at class.) If you would like to<br />

learn to do a macramé chair (cost $15, if you br<strong>in</strong>g your own (clean) chair frame)(if workshop<br />

facilitator supplies chair frame, cost will be more). There will also be f<strong>in</strong>ished items for you to<br />

purchase. This workshop is very <strong>in</strong>terest<strong>in</strong>g to see all <strong>the</strong> items that can be made. Special<br />

Note: When register<strong>in</strong>g for this workshop if you wish to make a chair, please make a note on<br />

<strong>the</strong> registration.<br />

-3-<br />

<strong>Girl</strong> Scout<strong>in</strong>g builds <strong>girls</strong> <strong>of</strong><br />

courage, confidence and character,<br />

who make <strong>the</strong> world a better place!


7SAM -- LEMMI STICKS (LUMMI STICKS OR RHYTHM STICKS)(9:30-11:00 am)(Anne Marie Shuey Wells)<br />

(Lummi sticks named after <strong>the</strong> Lummi Native American peoples) A great way to add excitement <strong>in</strong><br />

children's games. They are fun, easy to use and take up very little space. Lemmi sticks are<br />

generally struck aga<strong>in</strong>st one ano<strong>the</strong>r and used frequently <strong>in</strong> musical education to teach rhythm.<br />

This is great to teach <strong>girls</strong> <strong>of</strong> ALL ages! Come and learn how to use <strong>the</strong> sticks. Item you<br />

should br<strong>in</strong>g: Please br<strong>in</strong>g along a sit-upon.<br />

8SAM -- RECYCLING CRAFT -- GIFT BOXES MADE FROM GREETING CARDS -- (10:00-11:30<br />

am)(Diane Carpenter) Great craft project to recycle all types <strong>of</strong> greet<strong>in</strong>g cards. If you have any<br />

used greet<strong>in</strong>g cards lay<strong>in</strong>g around at home, please br<strong>in</strong>g <strong>the</strong>m along.<br />

9SPM -- CEREMONIES & SONGS -- (1:30-3:00 pm)(Anne Marie Shuey Wells & Mary Noel (Gus)<br />

Stenberg) Ga<strong>in</strong> <strong>the</strong> skills and confidence to help your <strong>girls</strong> design <strong>the</strong>ir own ceremonies. Learn<br />

<strong>the</strong> different types <strong>of</strong> <strong>Girl</strong> Scout Ceremonies and plann<strong>in</strong>g basics. This workshop will also<br />

<strong>in</strong>clude traditional <strong>Girl</strong> Scout songs used <strong>in</strong> ceremonies; fun songs to s<strong>in</strong>g on a hike or <strong>in</strong> <strong>the</strong> car<br />

head<strong>in</strong>g to an out<strong>in</strong>g; sweet songs; old songs; active songs and graces. S<strong>in</strong>g<strong>in</strong>g toge<strong>the</strong>r has<br />

been a <strong>Girl</strong> Scout tradition for <strong>100</strong> years. (If you desire, br<strong>in</strong>g a tape recorder and lot <strong>of</strong> batteries.)<br />

10SPM -- NO-SEW FLEECE PURSE -- (1:30-3:00 pm)(Cris Christ) Look<strong>in</strong>g for someth<strong>in</strong>g casual,<br />

yet funky? Well a No-Sew Fleece Purse is just <strong>the</strong> ticket! Go from scrap to fabulous <strong>in</strong> a mere<br />

hour to hour and a half. A great tween project, but, with some help <strong>young</strong>er <strong>girls</strong> may also be<br />

able to make! Items you should br<strong>in</strong>g: 1/2 yards each pr<strong>in</strong>t and pla<strong>in</strong> fleece material; sharp<br />

scissors.<br />

11SPM -- Council 101 (Section 5) & CAMPING 101 -- (1:30-3:30 pm)(Carole (Alfi) Ackerman)<br />

Council 101 - Section 5 -- Troop/Group Travel -- Any troop/group plann<strong>in</strong>g to take any form <strong>of</strong> a trip must<br />

have at least one representative complete Section 5 to serve as <strong>the</strong> Travel Certified Adult.) (Prerequisite:<br />

Volunteer Orientation.)<br />

Camp<strong>in</strong>g 101 -- Any troop/group plann<strong>in</strong>g to go on an overnight to a modern camp<strong>in</strong>g facility or any troop/<br />

group that would like to build a fire. This course certifies an adult to build a basic fire and roast marshmallows.<br />

Those travel<strong>in</strong>g and want<strong>in</strong>g to go tent camp<strong>in</strong>g and/or cook<strong>in</strong>g over a fire must take Outdoor<br />

Skills; this <strong>in</strong>cludes travel to any GSHPA sites and stay<strong>in</strong>g <strong>in</strong> platform tents. A modern camp<strong>in</strong>g facility is<br />

def<strong>in</strong>ed as a year round <strong>in</strong>door unit. (Prerequisite: Volunteer Orientation, Council 101: Sections 1, 2, and 5)<br />

12SPM -- FIRST AID & CPR -- (if needed)(same as 1SAM)(1:30-5:30 pm)(m<strong>in</strong>. 6; max. 10)<br />

(cost $40.00)<br />

13SPM -- MACRAMÉ WORKSHOP -- (same as 6SAM)(1:30-5:00 pm)<br />

14SPM -- SCRAPBOOKING -- (same as 4SAM)(3:00-5:00 pm)<br />

15SPM -- RECYCLING CRAFT -- GIFT BOXES MADE FROM GREETING CARDS -- (same as<br />

8SAM)(7:30-9:00 pm)<br />

16SPM -- 6 EASY CRAFTS TO DO WITH YOUR TROOP -- (7:30-9:00 pm)(Cris Christ) Creative<br />

items and projects that you can take back and teach your troop. Sparkly Snowflakes, Button<br />

Bracelets, Glamour R<strong>in</strong>gs, Lively Laces, Zipper Friendship Bracelet and Glitter Shakers. Items<br />

you should br<strong>in</strong>g: sharp scissors, 20-30 buttons different shapes/sizes and colors, one 6"-7"<br />

zipper any color (Cost $5.00)<br />

-4-


SUNDAY --<br />

FOXFIRE HOUSE TOUR/SCOUTS OWN -- (immediately follow<strong>in</strong>g breakfastfor<br />

everyone)(Carole (Alfi) Ackerman) Step back <strong>in</strong> time at Foxfire House<br />

while tour<strong>in</strong>g <strong>the</strong> house and outbuild<strong>in</strong>gs. Learn all about <strong>the</strong><br />

age-appropriate programs available for your troop. Experience life as an<br />

early Pa. German settler as <strong>the</strong>y lived here 150 years ago. From cook<strong>in</strong>g<br />

and bak<strong>in</strong>g to <strong>the</strong>ir chores, crafts, songs, games, garden<strong>in</strong>g and traditions.<br />

A weekend Live-<strong>in</strong> is a once-<strong>in</strong>-a-lifetime experience for <strong>the</strong> <strong>girls</strong> and you,<br />

<strong>the</strong>ir leaders.<br />

AVAILABLE ALL WEEKEND -- (no pre-sign-up necessary)<br />

**CERAMICS -- <strong>girls</strong> <strong>of</strong> ALL ages enjoy pa<strong>in</strong>t<strong>in</strong>g. (nom<strong>in</strong>al fees)<br />

**FREE TIME -- time to work on your own crafts, f<strong>in</strong>ish anyth<strong>in</strong>g you started <strong>in</strong> a workshop; play<br />

board games; socialize, read a book; just relax.<br />

Food Menu for <strong>the</strong> Weekend -- (Subject to Change)<br />

**FRIDAY EVENING...meatball sandwiches; bologna & cheese tray; vegetable tray; chips &<br />

pretzels; dr<strong>in</strong>k<br />

**SATURDAY...<br />

Breakfast...Baked oatmeal; eggs, sausage; potatoes; fruit; sticky buns; c<strong>of</strong>fee/tea/hot<br />

chocolate; juice<br />

Lunch...Vegetable soup; sandwiches; dessert; dr<strong>in</strong>k<br />

Supper...Chicken; potatoes; vegetables; roll & butter; dessert; dr<strong>in</strong>k<br />

**SUNDAY...<br />

Breakfast...Pancakes; fruit; donuts; c<strong>of</strong>fee/tea/hot chocolate; juice<br />

Throughout <strong>the</strong> weekend we will also have bottled sodas and bottled water and a few various<br />

snack items for sale at a reasonable cost.<br />

-5-


REGISTRATION<br />

Name _____________________________________________________<br />

Address ___________________________________________________<br />

City ___________________ State ________Zip Code _____________<br />

Daytime Phone Number ___________________ E-mail _____________________<br />

**Service Unit You Are From _____________________________<br />

**I am stay<strong>in</strong>g for <strong>the</strong> whole weekend..<br />

______Yes ______No (Please list when arriv<strong>in</strong>g and leav<strong>in</strong>g)__________________________<br />

**Buddy Request _____________________________________<br />

**Food Allergies (please see <strong>the</strong> menu on page 5. If <strong>the</strong>re is a menu item you cannot have,<br />

please list substitute.) ________________________________________________________<br />

**Special Physical or Health Issues for Unit Placement (please list):<br />

__________________________________________________________________________<br />

SEND REGISTRATION, PAYMENT, WORKSHOP<br />

CHOICES & HEALTH HISTORY INFORMATION TO:<br />

CRIS CHRIST<br />

224 W. SHERIDAN AVENUE<br />

ANNVILLE, PA 17003<br />

MAKE CHECKS PAYABLE TO:<br />

GSHPA - PINE MOUNTAIN SERVICE UNIT 703<br />

WORKSHOP<br />

SATURDAY<br />

MORNING<br />

SATURDAY<br />

AFTERNOON<br />

SATURDAY<br />

WORKSHOP CHOICES<br />

1ST<br />

CHOICE<br />

2ND<br />

CHOICE<br />

3RD<br />

CHOICE<br />

4TH<br />

CHOICE<br />

EVENING<br />

X X<br />

T-SHIRT SIZE...(PLEASE CIRCLE SIZE NEEDED)<br />

S M L XL XXL XXXL<br />

If <strong>the</strong> m<strong>in</strong>imum number <strong>of</strong> participants is not reached,<br />

<strong>the</strong> workshop will be cancelled. You must attend all<br />

workshops to which you are assigned.<br />

Payment Enclosed<br />

Weekend/Day Fee $_________<br />

Workshop Fees _________<br />

Total Amount $_________<br />

Check No. _________<br />

EMERGENCY CONTACT<br />

In case <strong>of</strong> emergency, <strong>the</strong> follow<strong>in</strong>g person,<br />

NOT AT THE EVENT, is authorized to act <strong>in</strong><br />

my behalf.<br />

______________________________________<br />

Name<br />

______________________________________<br />

Relationship<br />

______________________________________<br />

Area Code & Phone Number<br />

______________________________________<br />

Street Address<br />

______________________________________<br />

City State Zip Code<br />

Read Carefully<br />

Yes, <strong>Girl</strong> <strong>Scouts</strong> <strong>in</strong> <strong>the</strong> <strong>Heart</strong> <strong>of</strong> PA has<br />

my permission to use photos or<br />

video images taken at <strong>the</strong> Adult<br />

No,<br />

Volunteer Weekend <strong>in</strong> <strong>Girl</strong> Scout<br />

Scout publications, newspapers,<br />

electronic media, or video<br />

programs.<br />

x_________________________________<br />

Signature<br />

-6-


RELEASE OF MEDICAL INFORMATION AUTHORIZATION<br />

In accordance with <strong>the</strong> standards <strong>of</strong> <strong>the</strong> Health Insurance Portability and<br />

Accountability Act <strong>of</strong> 1996 (HIPAA), <strong>the</strong> follow<strong>in</strong>g provides for <strong>the</strong> release <strong>of</strong> medical<br />

<strong>in</strong>formation to <strong>the</strong> appropriate listed personnel.<br />

This is to authorize <strong>the</strong> release <strong>of</strong> medical <strong>in</strong>formation, to or between, Camp Staff and<br />

authorized Medical Personnel (<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> Health Supervisor, visit<strong>in</strong>g RN, and on-call<br />

doctor), hospital staff, food service staff and Unit Staff concern<strong>in</strong>g medications, illness,<br />

limitations or health conditions relat<strong>in</strong>g to<br />

____________________________________________'s participation <strong>in</strong> camp activities.<br />

(please pr<strong>in</strong>t participant's full name)<br />

I understand that by sign<strong>in</strong>g this, I authorize <strong>the</strong>se persons to receive my medical <strong>in</strong>formation<br />

on a need to know basis.<br />

________________________________<br />

Name <strong>of</strong> participant -- pr<strong>in</strong>ted (required)<br />

________________________________<br />

Signature <strong>of</strong> participant (required)<br />

_________________________<br />

Date (day/month/year)<br />

________________________________<br />

Parent/Guardian name pr<strong>in</strong>ted (if under 18 years <strong>of</strong> age)<br />

________________________________<br />

_________________________<br />

Parent/Guardian signature (if under 18 years <strong>of</strong> age) Date (day/month/year)<br />

This form is to be attached to your camper's Health History Form.<br />

-7-


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