** Please Take This Sheet Home With You For Your Reference **
Thank you for registering your daughter in “Outback Power Pack, Self Discovery Camp for Young Women”, August 26-30, 2013 located at Camp Tamarack. We think our camp is unique and special for two specific reasons: (1) “Our mission is to provide programming that gives young women the opportunity to explore
who they are and to use these discoveries to guide them.” We believe the camp experience provides the opportunity for self-discovery through adventure and fun.
(2) We are sponsored and funded by our community. Many volunteer hours have gone into
the planning of this year’s camp. Thanks to our sponsors we are able to keep the registration fee low and are able to provide the services of a bus both to and from camp.
The bus will be leaving for Camp Tamarack from the Multi-Rec Centre parking lot at 8:00 am August 26. We will return on August 30 between 4:00 pm & 4:30 pm. We have a great team of camp Counselors and Teen Leaders who have various backgrounds of working with children and youth. We, the steering committee and camp staff, are really excited about the activities we are able to offer this year! The attached forms need to be filled out and returned to the Multi-Rec Centre by August 12th. Having the forms on time helps us to be better prepared and organized. The catering company at Camp Tamarack also needs to know if your child has any dietary needs so they can plan and shop for meals. 1) Informed Consent Agreement (To be witnessed by a Town of Slave Lake Employee) 2) Permission Slip for Non-prescription Medications 3) Picture/video release form 4) Medical Form Also included in this package is the, SUGGESTED TO BRING LIST. Note, at the bottom of the page is a section for things NOT TO BRING. We ask that no junk food be brought to the camp. We will be operating our own snack shop. Outback Power Pack Bucks will be given to each camper. Please do not send any money or valuables (ie CD Player, ipod, etc.) with camp participants. A code of conduct is included in this package. We will also be discussing Camper’s Rights the first day of camp. We are looking forward to fun filled days of learning and adventure. If you have any concerns or want more details please call Michelle at 780-849-8023. ** Please Take This Sheet Home With You For Your Reference **
Out Back Power Pack Code of Conduct
Litter must be properly disposed of in the garbage receptacles
Do not use camp supplies (axes, shovels, etc.) unless you have
Please leave pets at home. Use the outhouses and washrooms provided by the camp. No swimming or canoeing allowed unless there is a life-guard on
duty. The buddy system will be in effect.
This is a tobacco, alcohol and drug free camp. NO SMOKING
Respect the forest - use the trails provided. Have respect and responsibility for yourself, others and the
Suggested To Bring List
water bottle (must bring)
sleeping bag (must bring)
appropriate clothing and outer wear for
You can bring cell phones and/or ipods
Please Do Not Bring Town of Slave Lake Outback Power Pack Girls Camp 2013 Informed Consent Agreement
Both The Participant And The Parent/Guardian Must Sign
Print Name Of Participant: ______________________________________________
Print Name of Parent/Guardian: __________________________________________ Dear Parent/Guardian and Participant: Thank you for choosing to use the programs and services of the Town of Slave Lake. We request your understanding and cooperation in maintaining both your own and our health and safety by reading and signing the following consent form. I am aware that each child participating in the Outback Power Pack Program (here in after referred to as the “Program”) wil have different capacities for participating in the Program. I am aware that the Program, is recreational, educational and in certain circumstances self-directed in nature and I acknowledge the risks and dangers may include but not be limited to: the hazards of travelling in forest and mountainous terrain, accident or illness in remote places, changing weather conditions, negligence of other Participants, travel by canoe, automobile or other conveyances, property damage, bodily injury, and possibly death to my child and/or others during this program. I understand that part of the risk involved in undertaking any activity or program is relative to ones own state of fitness or health (physical, mental or emotional) and the awareness, care and skill with which I/my child conducts myself/themselves in the Program. I acknowledge my/my child’s choice to participate in the Program brings with it the assumption by me/my child of risks or results stemming from this choice and the fitness, health, awareness, care and skill that I/my child posses(es) and use(s). In addition, I understand that I am free to withdraw myself/my child from, reduce or modify involvement in any program activity. I further understand that my child will be required to wear protective gear including but not limited to: a life jacket, a helmet, appropriate foot wear and clothing in order to participate in the Program. Furthermore, the personnel and volunteers associated with the Program do not profess to offer assessment or treatment of any medical or physical condition except where duly licensed, certified or registered to provide such professional services. It is my responsibility to determine whether or not I am satisfied with the qualifications of the Program personnel. In addition, I acknowledge that I have inquired about the nature of any activity, program or services that I am not completely familiar with and I have been informed of any inherent risks. I declare that I have had the opportunity to seek legal advice, have read and understand the information contained in this INFORMED CONSENT AGREEMENT prior to endorsing my/my child’s participation in the Program. Signature of Participant: ____________________Date of Signatures: ___________ Signature of Parent/Guardian: ___________________________________________ Signature of Witness: __________________________________________________
Printed Name of Witness: _______________________________________________ Permission Slip for Non-prescription Medications
Camper _________________________________ (please print) last name, first name This form is for permission to use “over the counter medications”, in non-emergency situations, (eg: Allergy attack, headache, etc.). These medications will not be freely accessible to the campers, and would be given by our First Aid person. If this form is not in the First Aid person’s possession at the time medication is needed, no medication will be given unless there is parental consent. Tylenol
______________________ ______________________ Parent’s/Guardians Signature
____________________________________________________________________________ RELEASE FORM I, ___________________________, parent/guardian of the child ___________________ Do hereby agree to give the Town of Slave Lake permission to take pictures of/ or video- tape my child while participating in the program for the purpose of future advertisement, promotion and publicity. Date:______________________ ___________________________ ________________________ Signature of Parent/Guardian Outback Power Pack 2013 Medical Form
Note: This form is to be signed by parent or legal guardian for campers or staff under the age of eighteen years old. Name: _______________________________________ (please print) first last Address: ______________________________________________________________ Postal Code: ____________ Phone: _________________ Age: _____ Birth Date: ____________ Alberta Health Care Number: ____________________ Blue Cross: _______________ Other: __________________
EMERGENCY CONTACT
1) Parent/Guardian: ________________________________________ last first Relationship: __________________ Phone:___________(H) ___________(W) 2) Alternate Contact: ____________________________________ last first Relationship: __________________ Phone: ___________(H) ___________(W) Is there any knowledge of past or present diseases or injuries: __Head
Other:________________________________________________________________ Is your child on any medications? No __ Yes__ Details:_______________________________________________________________ If the answer to any of the questions is “yes” please elaborate on dates, serious after-effects, etc. ___________________________________________________________ _____________________________________________________________________
Specify any allergies or reactions. e.g.: to drugs, bee-stings, grasses, nuts, animal fur, etc. ________________________________________________________________ ____________________________________________________________________ List any regularly carried medications, describe any medic tag worn. _____________ ____________________________________________________________________ Are there any restrictions in activities or diet? ________________________________ _____________________________________________________________________ Please describe any regular fitness program participated in. _____________________ _____________________________________________________________________ Swimming Ability (e.g.: level) _______________________________________________ Date and type of most recent immunization shots ______________________________ _____________________________________________________________________ Specific problems, physical or emotional, that the coordinator should be made aware of. (If any doubtful condition exists, please attach a doctor’s report). __________________ _____________________________________________________________________ Name of Family Doctor: __________________________________________________
This information is for the safety of your child and will be treated confidentially. In case of emergency, I understand that every responsible effort will be made to contact the stated emergency contact(s). In the event that they cannot be reached, I hereby give the staff permission to select a physician and provide that physician with the necessary consent to provide proper treatment. ______________________ ______________________ Parent’s/Guardians Signature
http://arbitratemediate.com/glossary.htm Action Lines The telephone complaint processing services, provided by individuals or organizations. Most commonly, action line programs are referred to as “offices of information and complaint” within government agencies, private industries, and the media. Adjudication The solution to a particular conflict as determined by a judge or admi
PATIENT INFORMATION: PATIENT NAME: ____________________________________________ DATE OF BIRTH: ___________________________________ AGE: ________________ SS#__________________________________ MARITAL STATUS: M S D W SEX: M F RACE: _____________________________________ PREFFERRED LANGUAGE: __________________________________________ ADDRESS: ____________________________________________________
** Please Take This Sheet Home With You For Your Reference ** 
** Please Take This Sheet Home With You For Your Reference ** 
Town of Slave Lake 
Permission Slip for Non-prescription Medications 
Outback Power Pack 2013 Medical Form 
Specify any allergies or reactions. e.g.: to drugs, bee-stings, grasses, nuts, animal fur, etc. ________________________________________________________________ ____________________________________________________________________ List any regularly carried medications, describe any medic tag worn. _____________ ____________________________________________________________________ Are there any restrictions in activities or diet? ________________________________ _____________________________________________________________________ Please describe any regular fitness program participated in. _____________________ _____________________________________________________________________ Swimming Ability (e.g.: level) _______________________________________________ Date and type of most recent immunization shots ______________________________ _____________________________________________________________________ Specific problems, physical or emotional, that the coordinator should be made aware of. (If any doubtful condition exists, please attach a doctor’s report). __________________ _____________________________________________________________________ Name of Family Doctor: __________________________________________________
This information is for the safety of your child and will be treated confidentially. In case of emergency, I understand that every responsible effort will be made to contact the stated emergency contact(s). In the event that they cannot be reached, I hereby give the staff permission to select a physician and provide that physician with the necessary consent to provide proper treatment. ______________________ ______________________ Parent’s/Guardians Signature