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IPCC 2015 SUMMER DAY CAMP REGISTRATION FORM
Indian Pueblo Cultural Center
Connecting with Culture through Experience
June 1-12, 2015 | M – F, 8:30-4:30*
Thank you for your interest in the Indian Pueblo Cultural Center Summer Day Camp! Here is some
important information for you to review as you register your camper this summer.
Important information:
Only 1 Session for students ages 6-12
Group 1: 6-8 year olds, Group 2: 9-12 year olds
Cost: $250 for 2 week camp, scholarship applications are available by request at
KOrtega@indianpueblo.org
Important Dates:
Monday, March 2nd: Registration and Scholarship applications available at the IPCC and online
Friday, May 1st: Deadline for registration
Saturday, May 30th, 10:00am-12:00pm: Pre-camp OPEN HOUSE
*Friday, June 12th will be a day of feasting and sharing; parents are invited to camp for lunch and
presentations of accomplishments, 12:00-2:30pm. Camp will end at 2:30pm that day.
Themes for our camp this summer include creativity, legacy of Pueblo culture, and stewardship. Campers will
explore and enjoy learning-through-experience about indigenous traditions in art, gardening, storytelling, culinary
arts, printmaking, pottery making, sculpture, painting, illustration, visits to the museum, watching traditional
dance, and more!
Please attend the pre-camp OPEN HOUSE on Saturday May 30th to meet the staff and receive an
introduction to the program.
Each camper will receive an IPCC string bag, water bottle, art journal, daily snacks, and opportunities to learn
from local experts.
For more information please contact Emma Lee Clarke: eclarke@indianpueblo.org, 505-212-7051 Indian Pueblo Cultural Center, 2401 12th Street, NW, Albuquerque, NM 87104
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Registration 2015 IPCC Day Camp, 2/15 version
IPCC 2015 SUMMER DAY CAMP REGISTRATION FORM
Parent or Guardian, please complete this packet of forms 1.
All required information must be complete before registration is accepted 2.
Make a copy for your records 3.
Return a completed form with your payment or scholarship application to IPCC 4.
Submit one form per child 5.
Children must be the stated age at the start of Day Camp 6.
Registration is considered complete when all registration materials are returned and fees have been paid or arranged by May 1, 2015 to IPCC 7.
Please mail or hand deliver this completed packet to: Indian Pueblo Cultural Center Attn: Kay Ortega 2401 12th Street, NW Albuquerque, NM 87104 __________________________________ ____________________ ______________ Child’s name Age (at time of camp) Date of Birth ____F ____M Parent or Guardian name (s) Parent/Guardian email address phone # Home address City State Zip Code Emergency Contact
In the event of an emergency, contact the following person(s):
Name:___________________________________Relationship:_________________________
Phone 1: (______) __________________ Phone 2: (_____)_____________________________
Name:________________________________Relationship:_____________________________
Phone 1: (______) ___________________Phone 2: (_____) _______________________
I, __________________________ (parent/legal guardian) do hereby solemnly affirm that I have legal custody
of the participant.
As the parent or legal guardian of _______________________ (child’s name) I allow him/her to participate in
the Indian Pueblo Cultural Center 2015 Summer Day Camp from June 1st to June 12th, 2015. I have carefully
read the policies for this camp and understand that there may be certain risks involved. I insure that I will
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Registration 2015 IPCC Day Camp, 2/15 version
IPCC 2015 SUMMER DAY CAMP REGISTRATION FORM
follow all policies and procedures. I also insure that I will instruct the participant to follow all instructions
explained to him/her by program leaders, volunteers and interns, and I assume all liability for the participant’s
failure to follow instructions. I understand that the program instructors may immediately withdraw the
participant from the program if she/he is unable or unwilling to follow instructions.
In consideration of the participant being allowed to participate in the program, I waive, release and discharge
the Indian Pueblo Cultural Center, Inc. Indian Pueblos Marketing, Inc., and its employees, agents,
representatives and volunteers, from any and all claims, liability and damages resulting directly or indirectly
from the participant taking part in the program, including but not limited to those: 1) arising from personal
injury and/or property damage suffered by the participant, whether resulting from the negligence or other
conduct, including all acts and omissions, of the IPCC, its employees, agents, or volunteers, the conduct of
another participant, the conduct of a non-participant, or from any other cause; 2) arising from the release or use
of medical information by the IPCC for the purposes of providing medical treatment to the participant; 3)
arising from the provision of such medical treatment; and 4) for the release of the custody of the participant to
the individual(s) identified and authorized by the parent/guardian; any and all of which actions may be
required to protect the participant’s health, safety, and welfare while participating in the program.
I have carefully read this authorization and I acknowledge that I fully understand its contents and agree for
myself and my child to be bound by all terms and conditions set forth therein. My signature is evidence of my
understanding and commitment to this authorization.
Parent/Legal Guardian signature: _________________________________
Date: _____________
-------------------------------------------------------------------------------------------------------------------------------- Camper Pick-Up
I, ___________________ authorize the following individuals(s) besides myself to pick up
______________________from the IPCC 20154 Summer Day Camp:
Name: _________________________________ Relationship:___________________________
Phone 1: (______) ________________ Phone 2: (_____)___________________
Name:__________________________________ Relationship:__________________________
Phone 1: (______) ________________ Phone 2: (_____) ____________________
Name:__________________________________ Relationship:__________________________
Phone 1: (______) ________________ Phone 2: (_____) ____________________
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Registration 2015 IPCC Day Camp, 2/15 version
IPCC 2015 SUMMER DAY CAMP REGISTRATION FORM
Medical Authorization Form
Section I: Authorization to Permit Medical Treatment. By signing below, I hereby give
permission to the Indian Pueblo Cultural Center, Inc., Indian Pueblos Marketing, Inc., its employees,
volunteers or interns (collectively referred to as the "IPCC") to provide first aid for any injuries or
illnesses experienced by the above-referenced minor, in my absence. If the injury or illness is lifethreatening or requires emergency treatment, I authorize the IPCC to seek medical assistance on
behalf of my child in the event I am unavailable to indicate my wishes regarding treatment. I
understand that the IPCC shall not be held responsible for the costs of treatment. I hereby grant
permission to emergency personnel, physicians and other licensed health care providers and their
designees to attend, transport, and administer medical care through injury or illness evaluation, first
aid care and referral to duly licensed medical personnel when indicated. I waive, release and
discharge the IPCC from any and all claims, liability and damages arising from the provision of such
medical treatment.
Please PRINT ALL INFORMATION
Name of Child: _______________________________________________
D.O.B. ___________________
Address:________________________________________ City: _____________________
State: _________________ Zip code_________________
Parent/Legal Guardian's Name: _______________________________________________
Daytime Phone: ( ___)_____________ Cell: ( _____) ____________________________
Email:___________________________________________________________________
I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION BELOW TO
EMERGENCY PERSONNEL AND TREATMENT PROVIDERS, AND WILL HOLD THE
IPCC IN NO WAY RESPONSIBLE FOR THE RELEASE OF THIS INFORMATION TO
ANY EMERGENCY PERSONNEL OR TREATMENT PROVIDER.
Please print all information
Child’s Name: _____________________________________________________________
Medical Insurer/Health Plan: __________________________________________________
Policy#: _______________________________________
Physician's Name: ______________________________ Phone #: ____________________
Date of Child's Last Tetanus Booster: ________________
Signature of Parent or Guardian: _________________________________ Date: _________
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IPCC 2015 SUMMER DAY CAMP REGISTRATION FORM
MEDICAL HISTORY INFORMATION – MINOR PARTICIPANT
This form requests medical history which must be completed by a Parent or Legal Guardian If the Participant takes any medications, please list medication name and dosage. The instructors and
volunteers cannot dispense prescription medicines. If the Participant must take a medication during
the Program, she/he MUST be able to take personal responsibility for the medications or have
parent/guardian administer the medicine.
Child Health History (Check those areas that apply. Please explain any check marks.)
Asthma Type __________________________________________________________
•
If the Participant has asthma, she/he must carry the asthma medication with them at all times. ____Bleeding/Clotting Disorders ________________________________________
____Convulsions ____________________________________________________
____Diabetes ______________________________________________________
____Frequent Ear Infections ___________________________________________
____Heart Defect/Disease ____________________________________________
____Hypertension____________________________________________________
____Musculoskeletal Disorders/Injuries___________________________________
____Seizures____________________________________________
Allergies/Allergic Reactions- (Specify reaction and management of the reaction.)
____Animals (animal and reaction) ______________________________________
____Food (food item and reaction) ______________________________________
____Hay Fever ______________________________________________________
____Bee Stings and reaction ___________________________________________
____Insect Stings (insect and reaction) ___________________________________
•
If the Participant has a known anaphylactic reaction to any insect stings, she/he must carry an Epi-­‐pen and an antihistamine with them at all times while outdoors. ____Medicines/Drugs (medicine/drug and reaction) ______________________________
____Other (specify) _________________________________________________________
____Penicillin _____________________________________________________________
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IPCC 2015 SUMMER DAY CAMP REGISTRATION FORM
____Poison Ivy_____________________________________________________________
Other Health Related Conditions
___Hearing Impairment
___Hepatitis___________________
___German Measles ____________
___Mumps ___________________
___Other (specify) ____________________
___Special Dietary Regimen ______________
Diseases
Chicken Pox______________________________
Measles________________________________
Other (specify) __________________________
Please provide any additional information that may be useful to the IPCC in relation to any of these
health conditions. Also, indicate any activities to be encouraged or restricted.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
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IPCC 2015 SUMMER DAY CAMP REGISTRATION FORM
Photo Consent Form
I, ______________________(parent or guardian) of _______________________
hereby grant permission to the Indian Pueblo Cultural Center to take photo and video
of the child listed above while he/she is enrolled in the Indian Pueblo Cultural Center
Summer Day Camp Program. I further understand and acknowledge that any
photograph or video taken by Indian Pueblo Cultural Center staff members may be
used in the Indian Pueblo Cultural Center’s newsletter, web site, flyers, brochures, or
fundraisers. Indian Pueblo Cultural Center may share photographs and videos with
parents or guardians; however, original negatives and video will remain the property of
the Indian Pueblo Cultural Center.
Signature Parent/Guardian
Date
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Registration 2015 IPCC Day Camp, 2/15 version