Washington

2015 Camp Shriver Camper Application

A parent or guardian for each camper applicant should complete this form. Please fax, scan, or mail the
completed application to Chara McElfish by May 1, 2015. Fax: 206-361-8158. Mailing address: 1809 7th
Ave, Ste 1509, Seattle, WA 98101. Email: cmcelfish@sowa.org
Camp will be held at Lazy F Camp & Retreat Center (Ellensburg, WA) June 23 through 26th. Applications
due by May 1, and acceptance notifications will be sent by May 8. Parents & guardians are responsible for
transportation of their camper to and from camp. If your applicant is selected to attend camp, payment is
due by June 1, 2015.

Applicants Full Name:

Preferred Name:

Address:
Gender: M F

City:

State:

Zip:__________

Camper Email:

Camper Age:

Camper Phone:

Camper Date of Birth:

Parent/Guardian Full Name:

Email:

______

T-Shirt Size:
Phone:

Emergency Contact Name:

Emergency Contact Phone & Email:

Name of HS currently attending:
Is this the campers first overnight without parents or guardians? Y

What sports does the camper currently participate in?

Grade: _____________
N____________________

Please list any leadership roles that the camper is involved in (Unified clubs, church groups,
etc.):___________

How did you hear about camp?

What new sports would the camper like to learn?

What kind of leadership is the camper interested in (public speaking, leading a club,
team captain, fundraising, etc.)

_____________________________________________________________________________________

Please have the camper write or transcribe why they would like to attend camp:

What other information do you feel we should know about the camper?

Behaviors:

Please circle any behaviors that the camper has experienced. Please be aware that 1:1 assistants will not
be available during camp, and the camper should be able to follow directions and participate with 4:1
camper to chaperone ratio.
Bites self/others

elevated sexual interest

overly dependent on others becomes

upset easily

exaggerates pain/illness

Pulls own hair/others

throws objectshits self/others

wanders/runs from group

Please explain any circled behaviors:

temper tantrums

Adaptive Skills
Please circle the word that best describes the camper for each area:

Dressing:

Independent

Needs minimal assistance

Needs significant assistance

Showering:

Independent

Needs minimal assistance

Needs significant assistance

Eating:

Independent

Needs minimal assistance

Needs significant assistance

Toileting:

Independent

Needs minimal assistance

Needs significant assistance

General Release

1. I am the parent/guardian of

, (the camper). I hereby represent that the

participant has my permission to participate in the activities at SOWAs Camp Shriver June 23 26. I
further represent and warrant that the participant is physically and mentally able to participate in such
activities.
2. I am specifically granting my permission on the campers behalf to Special Olympics Washington (SOWA) to
use the participants likeness, name, voice and words in television, radio, film, newspapers, magazines,
on the Internet and in all other media, and in any form, for the purpose of advertising or communicating
the mission and activities of Special Olympics and/or applying for funds to support Special Olympics.
3. I hereby irrevocably and exclusively assign to SOWA all copyright and other right, title and interest
(including moral rights) in and to the participants work product, including all photographs he or she may
take, videos he or she may make and articles/blogs/tweets/posts he or she may write, in perpetuity, to
use in all media, without further obligation to the participant.
4. If a medical emergency should arise during the campers participation in any Special Olympics activities, at a
time when I am not personally present so as to be consulted regarding the participants care, I hereby
authorize SOWA staff and volunteers to take whatever measures are necessary to ensure that the
participant is provided with emergency medical treatment, including hospitalization.
5. I fully understand that the activities of the camp may involve risks of serious bodily injury, including
permanent disability, paralysis and death, which may be caused by the participants own actions, or inactions,
those of others participating in the event, the conditions in which the event takes place, or the negligence
of the "Releasees" named below; and that there may be other risks either not known to me or not readily
foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs,
and damages I and/or the above named minor incur as a result of my and/or the participants participation
in the event.

I hereby release, discharge, and covenant not to sue SOWA and/or its respective directors, agents,
officers, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable,
owners and lessors of premises on which the event takes place, (each considered one of the "Releasees
herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be
caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue
operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk I, or
anyone on the participants behalf, makes a claim against any of the Releasees, I will indemnify, save, and
hold harmless each of the Releasees from any loss, liability, damage, or cost which any may incur as the
result of such claim.
6. I am the parent or guardian of the participant and I have read this RELEASE AND WAIVER OF
LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, AND PARENTAL CONSENT
AGREEMENT, and have explained these provisions to the participant. I understand that on behalf the
participant, I have given up substantial rights by signing this document and have signed freely and without
any inducement or assurance of any nature and intend it be a complete and unconditional release of all
liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to
be invalid the balance, notwithstanding, shall continue in full force and effect.

Signature of Camper, if 18:

Date

Signature of Parent/Guardian:

Date

Health History: To Be Completed by Parent/Guardian

Yes

No

Yes

No

*Heart Disease, Heart Defect or

High Blood Pressure

Contact lenses or glasses

*Chest Pain

Hearing loss or hearing aid

*Seizure, Epilepsy or fainting spells

*Asthma

*Diabetes

Easy bleeding

*Concussion or serious head injury

Emotional, Psychiatric, Behavioral

*Major surgery or serious illness

Sickle cell trait or disease

Heat stroke or exhaustion

Bone or joint problems

*Blindness or visual problems

Immunizations up-to-date

Medications (Name & Dosage):

Health Insurance Information

Health Insurance Provider:
Policy Number:
Policy Holder Name:

Allergy Information (Please list all relevant allergies)

Medicines:
Food:
Insect stings/bites:

Please use this space to provide us with any further information you feel would be helpful in determining if
Camp Shriver is a match for this camper:

Thank you!