You are on page 1of 12

CAMPS KATERI TEKAKWITHA 2010

REGISTRATION FOR YOUTH RESIDENTIAL AND FAMILY CAMP
CAMP TEKAKWITHA, THE YOUTH OFFICE AND PRAIRIE STAR RANCH ARE FUNDED IN PART BY THE ARCHBISHOP’S CALL TO SHARE.

ALL CAMPS ARE HELD AT: Prairie Star Ranch 1124 California Road Williamsburg, Kansas 66095

Mail Registration to: Youth Office 12615 Parallel Pkwy. Kansas City, KS. 66109
Camps Kateri entering 5th & 6th grades Term 1 Term 2 Term 3 Term 4 June 1-3 June 4-6 June 28-30 July 6-8 $230 $230 $230 $230 Camps Tekakwitha entering 7th & 8th grades Term 1 Term 2 Term 3 Term 4 June 7-12 June 14-19 July 10-15 July 19-24 $370 $370 $370 $370 Tekakwitha & X-Treme Entering 9th—12th graders Camp Tekakwitha June 21-26 $380 Tekakwitha-Extreme July 26-Aug 3 $430 Family Camp July 16-18 Ages newborn—2 Free (no babysitting provided) Ages 2 years and Up $125

GENERAL INFO
Prairie Star Ranch (PSR) is the beautiful, premium facility that hosts Camps Kateri Tekakwitha. The camps offer horseback riding, high ropes challenge, canoeing, hiking, orienteering, rock climbing, rappelling, basketball, soccer, swimming, group party games, archery, volleyball, mountain biking, mountain boarding, outdoor camping, softball, numerous Catholic prayer and sacramental experiences, and other outdoor camp activities. PSR’s cabins are air conditioned and heated as needed. Camp is a powerful spiritual experience that campers look forward to. Please reinforce the following policy protecting the high priority of faith development. It is assumed that all campers are staying for the entire session. Leaving and returning during a session is not permitted. Each camper is vital to the synergy of the cabin and camp dynamics. Please choose a camp session that does not conflict with sports or other engagements.

SAFETY
As parents, we understand that it is hard to leave your children, but we can assure you that our trained staff will make every effort to ensure the safety and well-being of your child during his or her stay. Our staff goes through a thorough screening process, receives training in their areas of responsibility, and they are backed up by a professional administrative team that evaluates and educates them throughout the summer. All staff are Virtus trained. A 1:8 counselor-to-camper ratio is used. Specific procedures are in place for campers to easily communicate concerns directly to the camp directors. To ensure the integrity of the camp, staff members will check all baggage as you arrive. Food, gum, candy, jewelry, cell phones, MP3 players, and valuable items are not allowed. If a family emergency occurs, or special circumstances require you to check on your child during camp, call Camp Tekakwitha office at 785-746-5693.

ALL INTERNET AND MAIL APPLICANTS MUST FILL OUT THE ENCLOSED CAMP REGISTRATION FORM.

Arrival/Departure Times
• • • • • • • • • • • June Kateri 1 June 1 arrive 9 a.m.; June 3 closing 7-8:00 p.m. Kateri 2 June 4 arrive 9 a.m.; June 6 closing 7-8:00 p.m. Jr. High 1 June 7 arrive 9 a.m.; June 12 closing 9:30-10:30 a.m. Jr. High 2 June 14 arrive 9 a.m.; June 9 closing 9:30-10:30 a.m Sr. High June 21 arrive 9 a.m.; June 26 closing 9:30 –10:30 a.m. Kateri 3 June 28 arrive 9 a.m.; June 30 closing 7-8:00 p.m. July-Aug. Kateri 4 July 6 arrive 9 a.m.; July 8 closing 7-8:00 p.m. Jr. High 3 July 10 arrive 9 a.m.; July 15 closing 9:30-10:30 a.m. Family July 16 arrive 10:30 a.m.:July 18 closing 3:00p.m. Jr. High 4 July 19 arrive 9 a.m.; July 24 closing 9:30-10:30 a.m. T-Extreme July 26 arrive 9a.m.; closing Aug 3 9:30 –10:30 a.m.

HOW TO REGISTER
REGISTER 7th thru 12th GRADE CAMPERS ON FEBRUARY 1st. REGISTER 5th & 6th GRADE CAMPERS ON FEBUARY 8th.

Online Registration. To register go to www.archkck.org and f ollow registration instructions. If you wish to become a member of our on-line community, go to “Login” and “Create a New Account”. Membership will insure your receipt of camp updates via e-mail. (Spam blockers will occasionally block the website e-mail, please check your settings.) Additionally, you must download a hard copy of the Campers’ Registration & Health Form and mail to the Youth Office to complete the registration process. Your online reservation will be matched to your hard copy Registration & Health Form upon receipt. U.S. Mail Registration. Registrations must be postmarked no earlier than Feb 1 or Feb 8. Registrations postmarked prior to Feb 1 or Feb 8 will be returned. No hand delivered registrations will be accepted. Hundreds of registrations are received via mail during the first few days of registration. Mailed forms are sorted at random by postmarked date as they are received in the daily mail. Many camp spots are available for registrations received through the mail; however, we encourage use of our online registration system. Spots are reserved on a first-come, first-serve basis. Each camper will need a completed Registration & Health Form, a photocopy of health insurance card, a wallet-size photo of camper (will not be returned), and a non-refundable $100 deposit. Final balances are due May 15 thru online or check payment options. Each camper will need to bring to camp on opening day, the Health Exam Waiver (one page Archkck form) or a sports physical, not more than 24 months old, signed by a medical professional. The Health Exam Waiver is attached to this packet.

Arrive 20-30 min. prior to closing for luggage pickup. Please honor the times listed above. Late arrival and early departures are strongly discouraged as welcome and closure are important parts of the total experience. In the event that a late arrival or early departure is necessary, it must be discussed with the camp director a.s.a.p. Your child will be permitted to ride home from camp ONLY with the persons listed on the registration form. Changing or adding names to the form maybe done at the time of check-in. Your signature is necessary to allow your child to ride home with anyone other than his/her parents or guardians. For safety reasons, campers are not permitted to drive themselves to camp.

CLOSING EVENT
The concluding program is VERY SPECIAL to share with your children. Please make sure you reserve this time for your child! The closing program will begin promptly as scheduled.

INCLUDED IN THE COST OF CAMP
The camp fee covers all necessary expenses. Food, snacks, lodging, activities, materials, etc. are provided. Camp clothing will be available to purchase for additional cost at check in on the first day of camp.

SCHOLARSHIP APPLICATIONS
Scholarship forms are available & requests are due January 20. If you miss this deadline, still apply in case funds become available.

PACKING LIST MAKE SURE TO BRING
WATER BOTTLE Pillow Sleeping Bag or Bedding Bug & Tick Repellant Sunscreen Sweatshirt or Light Jacket Towels & Washcloths Toiletries Flashlight Swimsuit (one piece) Jeans for horseback riding Seat Cushion (for outside) Swimming Shoes (no flip flops) Tennis shoes (extra pair may be used for swimming shoes) Shoes or boots with a firm hard covering and heels for riding (Tennis shoes may not be worn for horseback riding) MODEST comfortable casual clothes 1 package of note cards (3x5) Spiral notebook & pen 15 identical BEADS with a hole large enough for yarn Bible (Old & New Testaments) NAB version is the norm at camp
FAMILY CAMP PARTICIPANTS WILL BE MAILED A SPECIAL PACKING LIST

PACKING RESTRICTIONS/DRESS CODE
Our camps require an abundance of physical activity. We want to focus on deepening our faith and enjoying our outdoor adventure, and not on one another’s clothes or lost possessions. It is important to pack clothes that will be comfortable, safe, and modest (no tank tops or bare midriffs, please) during the athletic activities. Manufactured sleeveless shirts are allowed. We require a minimum of a 2” inseam on all shorts. Clothing that promotes non-Christian values will not be permitted. Cologne, make up, and jewelry need to be kept to a minimum. All baggage is thoroughly checked upon arrival to ensure a fun, spirit-filled, and safe camping experience for all. Good hygiene is also important; deodorant use and showering are strongly encouraged. All meals and snacks are provided by the camp. No outside food may be brought in, unless special dietary needs must be met. Pre-approval is required. Cabins are air conditioned when conditions dictate. Attic fans are installed in the cabins, but a small fan may be desirable. Thank you for your understanding and support.

CABIN MATES
At camp (not before) campers are notified of their cabin assignment. Roommate requests can be made on the Health Form. Under the following conditions, roommates requests are considered: 1. One roommate request per camper. 2. Camper A must request Camper B and Camper B must request Camper A. 3. Registrations MUST be mailed together, even if you register on-line.
Please remember, the spiritual experience of camp is our #1 priority.

OPTIONAL ITEMS
Small Fan Shower Shoes Disposable Camera(s) Stationary, pens & stamps (No stamps sold.)

DO NOT BRING THESE ITEMS
NO FOOD, MAGAZINES,CANDY OR GUM NO WEAPONS OR FIREWORKS NO VALUABLE ITEMS NO KNIVES OR TOOLS NO WIRELESS PHONES, PAGERS, ETC. CROCS FOR SHOWER SHOES ONLY

Please use the following numbers to answer your questions: Registration Questions (Calls returned in 24-48 hours) Camp Info Line 913-647-3054 or jenniferarchkck@sunflower.com Camp Policies/Camp Activities Shawn Madden 785-746-5693 or PrairieStarRanch@gmail.com Donations/Camp Safety Dana Nearmyer 913-647-0331 or youth@archkck.org, (June 1-Aug 8) 785-746-5693 To Download Forms and Brochures: go to www.archkck.org, Mary Rukavina 913 647-0373 or youthsec@archkck.org

CHARGES/REFUNDS
A $100 non-refundable deposit is due with each registration. The balance is due May 15. Registrations submitted after May 15 need to include full payment. If cancellation becomes necessary, and if your camper’s spot can be filled, you will receive a refund minus your deposit. Refund claims must occur within one month of the camp session closing. If a camper is wait listed and does not get into a camp, the deposit check is voided and destroyed.

From I-35, take the Williamsburg exit (# 170) and drive south, away from gas station, 8/10 of a mile to William Street. (Williamsburg’s main street). Turn right (west) on William Street and drive 1/10 of a mile. Turn left (South) on California Road (gravel road). Proceed approximately ¾ mile. Prairie Star Ranch is on the right (large stones mark entrance).

VISITORS/USE OF PHONE
Campers do not have access to phones. Camp directors will monitor any need for campers to use the phone. Parents may call office personnel to check on their child’s well being. We strongly encourage parents to write your child and place letters in inner-camp mail on opening day of camp; they really do enjoy getting your letters. Letters that are received, via the mail, after a camper has left, will be shredded. Only authorized guests are allowed on the premises during camp sessions. No pets allowed.

DIRECTIONS

SPIRITUAL FORMATION
Camps Kateri Tekakwitha combine demanding outdoor activities with powerful spiritual instruction bringing about a unique encounter with God. Although our adventure activities are memorable, often the love that campers experience through prayer is what kids remember most. Your child will have the opportunity to experience different forms of prayer during camp. Adoration, Reconciliation, veneration of the cross, rosaries, litanies, Mass, informal group prayer and individual reflection are among the many styles of prayer we practice here. These prayer experiences will have a lasting impact on campers ONLY IF they are lived out and continued. We encourage you to pray for your children during camp and with them after camp.

Registration Instruction Overview
Timeline and Methods of Registration:
♦ ♦

Registration begins for 7th thru 12th grade campers on February 1, 2010 (Online 9:00 a.m.). Registration begins for 5th & 6th grade campers on February 8, 2010 (Online 9:00 a.m.). ♦ Registrations postmarked and/or received prior to February 1st for 7th thru 12th grade campers will be returned. Registration postmarked and/or received prior to February 8th for 5th & 6th grade campers will be returned. Please respect the February 1st and February 8th registration dates or this could cause your child to lose his or her place! NO HAND-DELIVERED REGISTRATIONS WILL BE ACCEPTED. ♦ Camp sessions fill very quickly! Spots are reserved on a first-come, first-serve basis. Many camp spots are
available for registrations received through the mail. However, we encourage the use of our online registration system. Using online registration will give you instant confirmation. Mail applicants will receive a

confirmation or wait list letter three weeks after registration. Final balances are due May 15, thru online or check payment options. ♦ To register go to www.archkck.org and follow registration instructions. If you wish to become a member of our on-line community, go to “Login” and “Create a New Account”. Membership will insure your receipt of camp updates via e-mail. ♦ Registrations are not accepted without completed health forms, a photocopy of health insurance card, wallet size photo of camper (will not be returned) and a non-refundable and non-transferable deposit amount of $100. Each camper will need to bring to camp on opening day, the Health Exam Waiver (one page Archkck
form) or a sports physical, not more than 24 months old, signed by a licensed medical professional.

Please use the following numbers to answer your questions:
Registration Questions—Camp Info Line 913-647-3054 or jenniferarchkck@sunflower.com Camp Policies/Camp Activities—Shawn Madden 785-746-5693 or PrairieStarRanch@gmail.com Donations/Camp Safety—Dana Nearmyer 913-647-0331 or youth@archkck.org, (June 1-Aug 3) 785-746-5693 Please give us 24-48 hours to return your calls before calling again. To Download Forms and Brochures go to www.archkck.org. Camp brochure includes policies and procedures, arrival and departure times, directions, packing list, etc. Before you call, please check the website for the answers to your questions.

Family Camp:
The information in this packet does not completely explain family camp. Family camp is an extraordinary experienceabout which we love to spread the word. All families have their own “cabin.” All cabins are air-conditioned. Each family has its own wait staff. Meals are really fun. Tables are cleared by your personal wait staff. The price is all-inclusive, (no tipping please). Family camp brings families closer together. Teens, toddlers, parents and grandparents love family camp. Call Dana Nearmyer at 913-647-0331 or youth@archkck.org (June 1-Aug 8) 785-746-5693 if you have any questions about family camp.

Youth Residential Camp Scholarships are available. Applications are due January 20, 2010.
If you miss the scholarship deadline, you may mail your application late. In the event additional funds are donated, additional applications will be considered during the registration process. For specific questions regarding your application submission, e-mail jenniferarchkck@sunflower.com.

www.archkck.org register on-line!
INTERNET AND MAIL APPLICANTS MUST ALL TURN IN THE ENCLOSED REGISTRATION FORMS A.S.A.P. AFTER FEB 1, 2010 or FEB. 8, 2010

CAMPS KATERI TEKAKWITHA 2010
All Camps are Held at: PRAIRIE STAR RANCH 1124 California Road Williamsburg, Kansas 66095

HEALTH EXAM WAIVER
CAMPER’S NAME:_________________________________________________ CAMPER’S ADDRESS:______________________________________________ CAMP SESSION/DATE:_____________________________________________ CAMPER’S GRADE FALL 2010:______________________________________

_________________________________ (camper) is physically fit to attend camp at Camps Kateri Tekakwitha. The date of last exam was _________________________ (within the past 24 months). Please list current ongoing treatments or medications, if any.____________________________________________________________________.

Date_________________.

___________________________________ Licensed Medical Professional

Date_________________.

___________________________________ Parent or Guardian

The camps offer horseback riding, high ropes challenge, canoeing, hiking, orienteering, rock climbing, rappelling, basketball, soccer, swimming, group party games, archery, volleyball, mountain biking, mountain boarding, outdoor camping, softball, numerous Catholic prayer and sacramental experiences, and other outdoor camp activities. Not all activites will be available for 5th & 6th grade campers. No camper will be forced to participate in any activity at which they are uncomfortable.

THIS FORM SHOULD BE BROUGHT TO CAMP ON OPENING DAY. DO NOT MAIL.

Please mail to: Camp Tekakwitha Archdiocese of KC in KS

Registration Address: Camp Tekakwitha Archdiocese of KC in KS 12615 Parallel Parkway Kansas City, KS 66109 @ Prairie Star Ranch Camp Address: Prairie Star Ranch 1124 California Road, Williamsburg, Kansas 66095 Tel 785/746-5693

CAMPS KATERI TEKAKWITHA 2004 TEKAKWITHA 2010

12615 Parallel Parkway Kansas City, KS 66109

REGISTRATION & HEALTH FORM- FOR ALLYOUTH CAMPS
Very Important! Have you already reserved a spot online? YES/NO.
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Grade in upcoming year ___________ MALE FEMALE Phone # (_____)________________ Street Address _______________________________________Parent Email_____________________ City ___________________________________________ State ____________ Zip ______________ Parish __________________________________________ Parish City__________________________ Mother’s Name _________________________ Phone (Day) (____)________ (Evening) (____)_________ Mother’s Complete Address (if different than camper) ____________________________________________ Father’s Name __________________________ Phone (Day) (____)________ (Evening) (____)_________ Father’s Complete Address (if different than camper) _____________________________________________ Emergency contact (in case you can’t be reached) _________________________________________________ Phone # (____)_____________________ Relation to camper _________________________________ One cabin mate, of same gender and grade, request is permitted _______________________________ (See camp packet for cabinmate request details) Emergency numbers (cell phone numbers) for parents during camp week ________________________ ___________________________________________________________________________________

List Choices in Order From First To Last (1,2,3,4,).
Please note “N/A” for sessions that your camper is Not Available to attend.

Camps Kateri
Entering 5th & 6th grades Fall 2010 Term 1 June 1-3 $230______ Term 2 June 4-6 $230_______ Term 3 June 28-30 $230_______ Term 4 July 6-8 $230______
Please see brochure for arrival/departure times PRIOR TO registering your child Term 1 Term 2 Term 3 Term 4

Camps Tekakwitha
Entering 7th & 8th grades Fall 2010
June 7-12 June 14-19 July 10-15 July 19-24 $370_______ $370_______ $370_______ $370_______
Please see brochure for arrival/departure times PRIOR TO registering your child.

Tekakwitha & X-Treme
Entering 9th—12th grades in Fall 2010 (including graduating seniors)

Family Camp
July 16-18

Camp Tekakwitha
June 21-26 $380__________

Ages newborn—2 Free (no babysitting provided)

Tekakwitha-X-Treme
July 26-Aug 3 $430________
Please see brochure for arrival/departure times PRIOR TO registering your child.

Ages 2 years and Up $125 SEE FAMILY CAMP FORM TO SIGN UP

Page 1 of 3 Youth Residential Camp

Please note there are 4 required signatures!!!
Is this participant in general good health and able to participate in normal camp activities? Yes _____ No _____ Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____ (If upcoming appointment set, please note:_________________________________________________________.) ♦

!!!! VERY IMPORTANT !!!!
You MUST have written verification FROM LICENSED MEDICAL PERSONNEL that the camper has had a health examination during the past 24 months and the record SHOULD INCLUDE: any physical condition requiring restrictions on participation in camp and descriptions thereof, date of exam, and current on-going treatments or medications, and the record should be signed and dated. Please fill out our Health Exam Waiver (one page Archkck form) or a sports physical, not more than 24 months old, signed by a licensed medical professional. THIS INFORMATION MUST BE BROUGHT WITH YOU THE FIRST DAY OF CAMP. PLEASE DO NOT MAIL. (This Information Required by American Camping Association). (Health Exam Waiver form attached to camp packet.)

Doctor’s Name and Clinic:______________________________________________________________________ Doctor’s Full Address: _________________________________________________________________________ Doctor’s Phone #: (_____)____________________ Are all immunizations up to date? Yes _____ No _____ (If upcoming appointment set, please note:__________________.) Date of last tetanus booster: ____/____/____ (Tetanus Boosters are Required Every 10 years.) If any are not up to date please list them. _____________________________________________________________________ MEDICATION Allergies/Conditions: (Check if participant is allergic to any listed or has any of the following conditions) Bee Stings ______ Poison Ivy ______ Asthma ______ Fainting ______ Penicillin ______ Sulfa ______ Seizures ______ Hay Fever ______ Latex________ First Aid Antiseptics____ Antibiotics _____ Other ________ If any of the above were checked yes, please submit a statement in space provided below of how the child has been treated and with what medications. Please also list (use back of page 3 if necessary): 1. Any operations or serious injury in the past two years. 2. Medical limitations or needs that we need to be aware of. 3. Any limitations or needs (learning styles, family situations, custody arrangements, etc.)

If your son/daughter will be taking over-the-counter or prescription medications while at camp please list ALL medications (over-the-counter AND prescriptions) name, dosage and frequency on a 3x5 card and place in a ziploc bag with your child’s name on it along with the medications. Prescription medications must be in original container. Any changes in medication must be reported when registering at camp. No medication, even Tylenol, will be dispensed to your child other than what you provide, unless an emergency situation dictates. Please send Tylenol if you child is susceptible to headaches. The ziploc bag, and all other medication, prescription and non-prescription medication will be collected at registration and dispensed by the assigned team person. Youth may not keep ANY medication.

#1 Signature _________________________________________________________ Date ________________
(Parent or Guardian please sign even if child not on medication)

Page 2 of 3 Youth Residential Camp

Please list any special dietary needs for your child. ___________________________________________________ ____________________________________________________________________________________________ Notify the director if this child is exposed to any communicable disease during the three weeks prior to camp Parents will be notified of fever, vomiting, intense homesickness or anxiety, areas that require gauze bandaging, x-rays or stitching, and of other situations of concern to determine the course of action to be taken. In case of medical emergency, I understand that every effort will be made to contact parents or guardians of camper. In the event that I cannot be reached, I hereby request and give permission to the physician selected by the Camp to hospitalize, secure proper treatment for, and to order anesthesia or surgery for my child, as named herein. In signing this health form, I hereby certify that the information is correct and give permission for the release of medical records to an attending physician in case of illness or emergency. I request that my child be transported to seek needed medical attention.

#2 Parent or Guardian Signature ______________________________________________ Date _______________
Health Insurance Company ______________________________________________________________________ Health Insurance Policy # _______________________________________________________________________ Primary Health Insurance holder, name and Social Security # ________________________________________ A Photocopy of the Primary Health Insurance card MUST be submitted with this form. I request that my child ____________________ be allowed to participate in the camp activities at Camp Kateri or Camp Tekakwitha at the Archdiocesan Camp in Williamsburg, KS. I hereby release and indemnify the Archdiocese of Kansas City in Kansas, its staff, and volunteers from any liability arising from claims of any kind or nature whatsoever from my child’s participation in this program. The activities may include horseback riding, high ropes challenge, power kiting, stunt kiting, canoeing, hiking, orienteering, rock climbing, rappelling, basketball, soccer, swimming, technical tree climbing, group party games, archery, volleyball, mountain biking, mountain boarding, outdoor camping, softball, numerous Catholic prayer experiences, and other outdoor camp activities.

#3 Parent or Guardian Signature__________________________________________ Date ________________
Full Address _________________________________________________________________________________ Signature of Custodial Parent (if applicable) ________________________________________________________ PHOTO RELEASE I hereby authorize the Archdiocese Of Kansas City in Kansas, and its agents to utilize my child’s photographic image for the specific purpose of publication of the Archdiocese Of Kansas City in Kansas events (including promotional materials). In giving my consent, I hereby release and hold harmless the Archdiocese Of Kansas City in Kansas and its agents from any and all responsibility or liability. I understand that I will receive no compensation, should any photograph of me or my child be used.

#4 Parent or Guardian Signature __________________________________________________ Date _____________
TRANSPORTATION HOME At the conclusion of camp, your child will be leaving with his/her parents. Yes _____ No _____ I am not able to pick up my child from camp; he/she has my permission to ride home with ___________________________ Camper will not be allowed to leave with anyone who is not named on this form.

Page 3 of 3 Youth Residential Camp

COMPLETING REGISTRATION—Registration is NOT complete without the following items: 1. Make sure all blanks on the form are complete and all four signature blanks are signed. 2. Enclose a photo copy of health insurance card. 3. Send a wallet-size photo of camper (will not be returned). 4. En 5. 6. Enclose a $100 non-refundable deposit check made payable to Camp Tekakwitha. 5. Earliest ACCEPTED postmark date: February 1, 2010, for 7th thru 12 grade campers and February 8, 2010, for 5th & 6th grade campers. Earlier postmarks will be returned!

FAMILY CAMP TEKAKWITHA 2010
Prairie Star Ranch
Please mail to: Camp Tekakwitha Archdiocese of KC in KS 12615 Parallel Parkway Kansas City, KS 66109

REGISTRATION & HEALTH FORM
FOR July 16-18 FAMILY CAMP ONLY
Age Age 0-2 (no babysitting) Ages 2 years old and up TOTALS Please print and use blue or black ink only. Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___ Home Phone # (_____)________________ Additional Phone # (_____)________________ __________ ________ __________ $125 ________ # of campers __________ Cost FREE Total ________

Street Address ________________________________E-mail Address _________________________ City ___________________________________________ State ____________ Zip ______________ Parish _________________________________________ Parish City__________________________ Mother’s Name ________________________ Phone (Day) (____)________ (Evening) (____)_________ Mother’s Complete Address (if different than above) ____________________________________________ Father’s Name _________________________ Phone (Day) (____)________ (Evening) (____)_________ Father’s Complete Address (if different than above) _____________________________________________ Additional Emergency contact in case you cannot be reached (not at camp):
_______________________________________________________________________________________________

Phone # (____)_____________________ Relation to parents _________________________________

Family Camp Page 1 of 3

FAMILY CAMP TEKAKWITHA 2010
Prairie Star Ranch
Page 2of 3 of Family Camp Registration

Please note there are 3 areas requiring signatures!!!
Doctor’s Name and Clinic:______________________________________________________________________ Doctor’s Full Address: _________________________________________________________________________ Doctor’s Phone #: (_____)____________________ Are all immunizations up to date? Yes _____ No _____ Dates of last tetanus booster for each family member: ________________________________________________ ________________________________________________________________________________________ If any are not up to date please list them. __________________________________________________________ Please list any special dietary needs for your family. _________________________________________________ ________________________________________________________________________________________ Notify the staff if any family member is exposed to a communicable disease during the three weeks prior to camp.

Allergies/Conditions (List which family member is allergic to or has any of the following conditions): Bee Stings ______ Poison Ivy ______ Asthma ______ Fainting ______ Penicillin ______ Sulfa ______ Seizures ______ Hay Fever ______ Other _______________________________________________________________________________________
If any of the above were checked yes, please submit a statement in space provided below of how the family member has been treated and with what medications. Please also list (use back of page 3 if necessary): 1. Any operations or serious injury in the past two years. 2. Medical limitations or needs that we need to be aware of. 3. Any limitations or needs (learning styles, family situations, custody arrangements, etc.) Are all of youth family member that are coming to camp in general good health and able to participate in normal camp activities? Yes _____ No _____

!!!! VERY IMPORTANT !!!!
You MUST have written verification FROM LICENSED MEDICAL PERSONNEL that the camper has had a health examination during the past 24 months and a record SHOULD INCLUDE: any physical condition requiring restrictions on participation in camp and descriptions thereof, date of exam, and current on-going treatments or medications, and record should be signed and dated. If you already have a sports physical form from the past 24 months, it will also be sufficient for verification of campers’ health, or use our Health Exam Waiver (one page Archkck Form) included in this packet. THIS INFORMATION MUST BE BROUGHT WITH YOU THE FIRST DAY OF CAMP. PLEASE DO NOT MAIL. (This Information Required by ACA). Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____ Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____ Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____ Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____ Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____ (If upcoming appointment set, please note:__________________________________________________.) In case of medical emergency, I understand that every effort will be made to contact parents or guardian of camper. In the event that I cannot be reached, I hereby request and give permission to the physician selected by the Camp to hospitalize, secure proper treatment for and to order anesthesia or surgery for my child, as named herein. In signing this health form, I hereby certify that the information is correct and give permission for the release of medical records to an attending physician in case of illness or emergency. I request that my child be transported to seek needed medical attention.

#1 Signature of Parent/Guardian___________________________________________ Date _____________

Family Camp Page 2 of 3

FAMILY CAMP TEKAKWITHA 2010
Prairie Star Ranch
Page 3 of 3 of Family Camp Registration

#1 Signature of Parent/Guardian___________________________________________ Date _____________ #1 Signature of Adult Family Member_______________________________________ Date _____________ #1 Signature of Adult Family Member_______________________________________ Date _____________
Family Camp Page 3 of 3
Health Insurance Company ______________________________________________________________________ Health Insurance Policy # _______________________________________________________________________ Primary Health Insurance holder and name and Social Security # ________________________________________ A Photocopy of the Primary Health Insurance card MUST be submitted with this form. I request that my family ____________________ be allowed to participate in the camp activities at Family Camp Tekakwitha at the Archdiocesan Camp in Williamsburg, KS. I hereby release and indemnify the Archdiocese of Kansas City in Kansas, its staff, and volunteers from any liability arising from claims of any kind of nature whatsoever from my child’s participation in this program. The activities may include horseback riding, high ropes challenge, power kiting, stunt kiting, canoeing, hiking, orienteering, rock climbing, rappelling, basketball, soccer, swimming, technical tree climbing, group party games, archery, volleyball, mountain biking, mountain boarding, outdoor camping, softball, numerous Catholic prayer experiences, and other outdoor camp activities.

#2 Signature of Parent/Guardian___________________________________________ Date _____________ #2 Signature of Parent/Guardian___________________________________________ Date _____________ #2 Signature of Adult Family Member_______________________________________ Date _____________ #2 Signature of Adult Family Member_______________________________________ Date _____________
PHOTO RELEASE I hereby authorize the Archdiocese Of Kansas City, and its agents to utilize my child’s photographic image for the specific purpose of publication of the Archdiocese Of Kansas City events (including promotional materials). In giving my consent, I hereby release and hold harmless the Archdiocese Of Kansas City and its agents from any and all responsibility or liability. I understand that I will receive no compensation, should any photograph of me be used.

#3 Signature of Parent/Guardian___________________________________________ Date _____________ #3 Signature of Parent/Guardian___________________________________________ Date _____________ #3 Signature of Adult Family Member_______________________________________ Date _____________ #3 Signature of Adult Family Member_______________________________________ Date _____________
Please mail to: Camp Tekakwitha Archdiocese of KC in KS 12615 Parallel Parkway Kansas City, KS 66109 Registrations MUST BE postmarked; hand delivered registrations will NOT be accepted.