CAMP VICTORY MILITARY ADVENTURES
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Camper Application
Weekend Warrior
BOYS 7-11 YEARS OLD
With
this application, please enclose:
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Immunization
record
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Copy
of insurance card
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Copy
of birth certificate
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Record
of a physical examination completed within the last 30 days
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The fee for Camp Victory
Military Adventures Weekend Warrior Program is:
A check or money order
payable to Southeastern Military Academy must be enclosed with
the application.
We also accept Visa &
Mastercard. If you would like to pay by credit card, please call Molly @
772-621-9104 prior to returning your son’s application.
If for any reason your son
is unable to attend camp after his application has been processed, our
monetary return policy is as follows:
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One month prior to the
camp date, you may request another date or up to $100 of the fee be
returned to you.
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Less than 30 days prior
to camp date but before opening of camp, you may request another date or up
$25.00 of the fee be returned to you.
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If we reject the
application, thereby denying your son’s enrollment in the program, the full
amount will be refunded to you.
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If for some reason your
son cannot attend a scheduled camp. He may attend another camp in the same
calendar year as determined by administration.
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After acceptance of your son a complete information
package will be mailed to you with all pertinent information, as well as
available class dates for camp.
If you have questions please call Molly at 772-621-9104
Or
email at mollyvch@aol.com
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Camp victory military adventures-weekend warrior
camp - Application
Applicants will not be accepted
unless all areas of the application are completed. Please enclose copies of the
following : immunization records,
a current physical exam, a copy of the child’s insurance
card, and a copy of the child’s birth certificate.
Name: Last
grade completed in school ___________
Social
Security Number
Birth Date
(MM/DD/YYYY) ______/_______/___________
Parent(s)/Guardian’s name
Mailing address
City State _____
Zip
Email:
_________________________________________
Phone Numbers: Home
_____________________ Work
____________________ Cell
Language child speaks-
______________________________________
Church Preference
Emergency contact name and phone
number
Does your child know how to
swim? ________ Are there any restrictions?
Insurance Carrier or plan name ___________________________ Group #
Carrier address & telephone
number
Relationship to boy
Social security number of
policyholder or insurance ID number
Camper
Information- PLEASE BE ACCURATE
Height _________________ Weight
_________________________
Shoe
Size _______________ Boys
_______________
Mens______________________
Trouser Waist _____________________inches_ Length _______________________inches
Length( measure from inside of leg against groin to CENTER
of ankle)
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Shirt ( Chest size in inches measured
around chest under armpits)
Shirt ___________________inches
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Release
of Liability Agreement
__________________, my son, has
my permission to participate in the activities at TCVCH & SEMA’s Camp
Victory
Military Adventures program,. In
consideration of my son’s attendance in the program, I understand I am accepting
full
responsibility for my son. If an accident should occur injuring my son,
including, but not limited to, death or serious injury,
I, on behalf of myself, my heirs,
or successors, hereby release Camp Victory, Southeastern Military Academy and
TCVCH Inc. and their trustees,
directors, officers, agents, employees, counselors, or residents from any
liability.
I have filled out the information
regarding my family insurance policy. I
understand that any expenses incurred
for medical treatment of my son will
be my responsibility. I agree on behalf
of myself and my heirs and successors
to indemnify and hold harmless the Camp Victory program , SEMA and
TCVCH Inc., from any loss, cost, judgment
or other harm, including attorney
fees, which might come to them arising from my child’s attendance at Camp
Victory Military Adventures.
I have read and understand the
above agreement and I agree to abide by the CVWC policies included with this
application.
___________________________________________ __________________________
Signature of Parent or legal guardian Date
Permission to use photos/videos
I grant permission for TCVCH, Inc. to photograph, record, or
video tape my son during the program and to use those
materials for promotional or other purposes.
___________________________________________
Signature of parent or legal guardian Date
Participant Health
History
Childs Name
____________________________
The following information must be
completed by the parent/guardian. The
intent of this information is to provide
Camp Victory health care
personnel the background of the camper, in order to provide appropriate care.
Allergies – list all known allergies and describe the
reaction and treatment:
Medication allergies:
Food allergies:
Insect stings:
Asthma:
Animal dander
Poison Ivy
Seasonal allergies
Other allergies
Is there any particular
information about your son (medical, dietary treatment, ongoing medication,
allergies, special circumstances, etc.)
that you want to be certain the
Program Director and/or staff is aware of?
If so, please give a detailed explanation.
(You may attach another sheet, if
needed.)
Physical restrictions or disabilities
____________________________________________
Medications being taken:
_____ My son takes NO medications
on a routine basis
_____ My son takes medications as follows:
Med
#1 ___________________________ Reason________________________
Med
#2 ___________________________ Reason________________________
Attach additional pages for more
information
This health history is correct and complete as far as I
know, and the person herein described has permission to engage in all camp
activities.
Childs Name
____________________________________________
Printed Name of Parent/Guardian
Permission
to Provide Medical Treatment or Emergency Care
I hereby give permission to
TCVCH, Inc., SEMA, Inc. and Camp Victory Military Adventures to make any and
all arrangements
deemed appropriate and in the best
interest of my son for medical, surgical, and dental care. In the event I
cannot be reached in
an emergency, I hereby give
permission to a healthcare provider to secure and administer treatment,
including hospitalization, for my son.
I understand that parental
permission is required for operative procedures on minors. By signing this
form, I am giving my permission that
operative procedures may be
promptly carried out. I understand that all the costs related to such care are
my responsibility. I understand
that neither TCVCH, Inc.,or SEMA,
Inc. are not responsible for my son’s pre-existing injuries or illnesses or any
aggravation of these conditions.
I understand that TCVCH, Inc, or
SEMA will not assume responsibilities for illness or injury incurred while my
son is participating in
activities at Camp Victory
Military Adventures.
Name of
Participant_____________________________________________________
Signature of Parent/Guardian _____________________________________________
Billing Information:
Parents
Name___________________________________________________________
Address________________________________________________________________
City_________________________State_____________
Zip______________________
I/we, the parent(s) and/or legal
guardian(s) of ______________________________, have carefully read the
foregoing
agreement and know the contents
thereof, including any attached exhibit(s) and I/we have executed same of
my/our
own free will and voluntary act.
We agree to pay the program fee for our son to be in the Camp Victory Military
Adventures Program.
The fee per camp session is as follows: $550.00.
A check or money order
payable to Southeastern Military Academy must be enclosed with
the application.
We also accept Visa and
Mastercard. If you would like to pay by credit card, please call Molly @
772-621-9104
prior to returning your
son’s application.
WITNESS my (our) hands and read
this _______day of ___________, 20
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Father (or Guardian) Mother
(or Guardian)
Before
me personally appeared and ,
who after
first being duly sworn, identified and known to me to be the person(s)
who executed
the foregoing application as q being personally known or q showing identification
(type of ID), acknowledge the same to
be true and correct on the
day of ,
20 .
My Commission expires
Notary Public
Camp Victory Military adventures –weekend
warrior
For boys 7-11 years old
Release Form
As the parent of ,
I (or we if both parents are signing the document, although references will be
made to the singular in this document) , ,
am
aware of the following expectations regarding my association with Treasure
Coast Victory Children’s Home, Inc., SEMA, Inc.
and
the Camp Victory Military Adventures program, hereafter referred to as TCVCH,
SEMA and CVMA, as they care for my son.
1. As TCVCH will work hard to help my son, I am committed
to keep my son in the Camp.
2. I can expect there to be a lot of emotional blackmail
directed at both CVMA and me while my son tries every alternative to escape
accountability.
3. Both myself as a parent and CVMA can expect that lies
and half-truths will be expressed, especially at the beginning.
4. Each party needs to check out any statement that is
hard for them to believe or accept, by asking the other party for an
explanation.
5. Open communication is essential to avoid my son making
a split between CVMA and me. Just as in
a father/mother association,
I must
support the CVMA in my son’s presence, or he will continue trying to manipulate
people even after he leaves the program.
6. I realize that my son will be sleeping, eating, and
otherwise living outdoors, and I am fully agreeable to his being in primitive
surroundings
for the duration of this program.
7. I understand for my son to participate in this
program, I must, and will, provide CVMA with a fully completed application,
a copy
of his immunization card that shows all his immunizations are up-to-date, and I
will check his head for lice one
week
prior to his coming. If I find he has lice, I will treat it immediately.
8. I agree to indemnify CVMA, TCVCH, Inc. and SEMA, Inc.
and its officers, directors, employees, employers,
volunteers,
agents, and staff (collectively “CVMA”) against any and all liability, loss, or
damage that CVMA may
suffer
as a result of claims, demands, costs, or judgments of my son arising out of
CVMA’s care and custody of my son
during
his time in the program.
9. It is my understanding that certain of the activities
in which my son may/will participate will occur at locations other
than
CVMA, and that such activities may be under the supervision of persons who are
volunteers. These volunteers are
also
not held responsible for any accident that may occur while my child is under
their supervision.
Regardless,
I grant permission for my son to participate in such activities.
10. Following is a list of activities; I agree to initial ALL
of these activities. My son may participate in one or more,
and
possibly all, of these activities, although no guarantee is made that my son
will participate in any of these activities.
I must
initial all of these activities because if the group of boys in Camp Victory
Military Adventures
participates
in any of these activities, it would be counterproductive for the program to
keep some of the boys
from
participating. I understand the risks involved in the participation of the
below-mentioned activities,
and I
further give permission for my son,
______________________________________________ to participate in the activities
initialed.
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Picture
& first name to be used on TV, radio, or video production for
informational & promotional purposes.
Participating
in required church attendance
Participating
in Bible studies
Vocational
training
Being around
and working with animals
Working with
machines such as mowers, weed-eaters, drills and saws
Community
volunteering
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Wilderness
Skills training
Practical
application of Wilderness Skills
Sleeping,
working, eating, playing, & otherwise living outdoors
Working for
consequences when violating rules or directives by completing activities such
as running, push-ups, cleaning camp, chopping wood, and/or other activities
as designated by program staff
Backpacking
and/or hiking
Paintball
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11.
I agree to initial ALL of the following reward
activities, thereby expressing my permission for my son to participate in them.
only and may or may not occur. I
understand the risks involved in the participation of the below-mentioned
activities,
and I further give permission
for my son, ________________________________________________to participate in
all the activities.
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Riding in a boat, canoeing,
or tubing
______ Firearms Safety Training
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Shooting a Firearm on a range
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Participating in recreational activities
Swimming
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12.
My preference as the parent, if my son is on behavior
modification drugs, is made known to
CVMAas
indicated below by my initialing my consent to:
Continue behavior modification drugs while my son is in the
program.
Discontinue the drugs while my son is in the program. ( Requires a Doctors note allowing such.)
13.
Having read the above areas, I am in complete agreement with
everything listed above and so will support those areas
and all
others included in the Camp Victory Military Adventures program as operated by
TCVCH and SEMA.
I realize
that if I am not completely in agreement, I can withdraw my son’s name as a
possible candidate for
enrollment at
the Camp Victory Military Adventures program at this time.
Parent or
Guardian Signature Date
Parent or
Guardian Signature Date
Before
me personally appeared and ,
who after
first being duly sworn, identified and known to me to be the person(s) who
executed the foregoing application
as q
being personally known or q showing identification
(type & number of ID), acknowledge
the same to be true and correct
on the day of ,
20 .
My Commission expires:
Notary
Family
Information
Father/Guardian:
DOB:
Career/Work:
Hobbies/Interests:
Mother/Guardian:
DOB:
Career/Work:
Hobbies/Interests:
Sibling #1: Relation: DOB:
Hobbies/Interests:
Sibling #2: Relation: DOB:
Hobbies/Interests:
Sibling #3: Relation: DOB:
Hobbies/Interests:
Sibling #4: Relation: DOB:
Hobbies/Interests:
YOU MAY MAIL THIS APPLICATION ALONG WITH YOUR ENTIRE
ENROLLMENT FEE TO:
Camp Victory Military Adventures
C/O Southeastern Education Group
638 SW Biltmore Street
Port St Lucie FL 34983
Please make checks payable to: Southeastern Military Academy
We also accept Master Card and Visa
BIOGRAPHICAL DATA
Please answer the following questions completely. Feel free
to use another sheet if necessary.
1.) Does child have a bedwetting problem? ____________ If
yes explain i.e. How long? When
started?
Are meds prescribed? Do they work?
______________________________________________________
____________________________________________________________________________________.
2.) Does child frequently wet or defecate in clothes?
____________ If yes explain. __________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3.) Does child have a history of starting fires?
____________ If yes explain. _______________________
____________________________________________________________________________________
____________________________________________________________________________________
4.) Has child ever
been sexually or physically abused?
_______ if yes explain.
_____________________________________________________________________________________
_____________________________________________________________________________________
5.) Has the
child ever been in an accident?
_________ If yes explain
_____________________________________________________________________________________
6.) Has the child ever used drugs or alcohol? ____ yes ____
no
7.) Has the child ever attempted suicide? ____ yes ____ no
8.) Does the youth bruise easily or do bruises stay longer
than normal? _______ If yes explain.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________