welcome to camp nawakwa! - Camp Fire Inland Southern California

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WELCOME TO
CAMP NAWAKWA!
The following is information about our Camp Nawakwa Resident Camp program,
as well as important paperwork needed to complete the registration process.
Please complete the necessary forms indicated.
Thank you.
This institution is an equal opportunity provider
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, age, or disability.
CAMP FIRE INLAND SOUTHERN CALIFORNIA
9037 Arrow Route, Suite 140, Rancho Cucamonga, CA 91730
(909) 466-5878
(909) 483-5042 Fax
www.campfiretoday.org
Welcome to Camp Nawakwa!
If you have never been to our camp, let us tell you a little about it…
Camp Nawakwa is located in the San Bernardino Forest’s Barton Flats area at an elevation of 6,860 feet. The
beautifully wooded site is adjacent to the Mount San Gorgonio wilderness area. Since 1947, it has been
owned and operated by Camp Fire Inland Southern California which endorses the Camp Fire traditional
belief that the outdoors is an exciting place to be enjoyed and respected. Camping is a radical change from
the home and school environments where all may experience feelings of adventure, wonder, and joy. The
natural environment is a model of inter-dependency at the highest level.
THE PROGRAM
Campers will have the opportunity to participate in preplanned activities which include: swimming, hiking,
cooking outdoors, canoeing, arts and crafts, singing, drama, games, nature walks, archery, wall climbing,
making new friends, and having a lot of fun with a military theme.
THE SITE
A heated pool, dining hall, several clusters of fully enclosed cabins, bathroom facilities with running water, an
infirmary, wilderness trails, an archery range, a climbing wall, a nearby lake and lots of tall trees make up the
campsite. Cabins have bunks and mattresses...campers bring sleeping bags and pillows. Boys and girls live in
separate areas of camp and interact during activities, meals, and campfires. Standards for acceptance and
participation in all camp programs are the same for everyone without regard to race, color, national origin,
religion, age, sex or handicap providing program requirements are met.
REGISTRATION/FEE
To register, you are required to send your camp registration materials, one registration packet for each
camper, filled out completely. Failure to return all required forms on time may result in the forfeiting your
child’s spot at the camp.
HEALTH & SAFETY
Each camper must submit a completed and signed Health History form before attending camp. A Camp
Nurse will oversee the health care of all campers and staff, and provide care according to a physician’s
standing orders. Pool and lake activities are always supervised by Red Cross certified Lifeguards.
PARENT NOTIFICATION
Should a camper become ill or injured during camp, parents/guardians will be notified by camp personnel, be
advised of the situation, and appropriate care determined and implemented. At Camp Nawakwa, fun is the
focus, group activities and cooperation are emphasized, and friendship and learning are the results.
TELEPHONE
DO NOT SEND A CELL PHONE WITH YOUR CHILD. Campers do
NOT use the telephone except in very unusual circumstances, and then the Camp
Director would contact you first.
If an emergency arises at home and you should need to contact your child at
camp, call (909) 600-4072 Please note, this number is for emergencies only. All
1
other calls will be referred to the Camp Fire office (909) 466-5878.
LETTERS
We encourage all parents to send their campers mail, as it brightens their day and
lets them know that you’re thinking of them.
As the camp session is short mail your letter(s) the day your camper goes to camp or a
couple of days before or place letters in a large envelope, marked with your child’s
name and give to one of the check in staff once you arrive at Camp or if coming by
bus to one of the staff at the bus check in (the bus option is provided only for the
Aloha session). If you choose to mail you letters please mail to:
MAILING ADDRESS:
Session Name
Camp Nawakwa
4650 Jenks Lake Road East
Angelus Oaks
CA 92305
LUGGAGE/NAME TAGS
Please have child’s suitcase, backpack, pillow and sleeping bag tagged with their name.
The children will be responsible for locating their belongings.
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
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Old clothes are best to send to camp
A warm sleeping bag and a warm jacket or coat are necessities
Do not send a cell phone with your child
Do not send food or snacks with your child
IMPORTANT DO NOT PACK MEDICATIONS FOR FIRST DAY MEDICATIONS ARE
TURNED IN AT CHECK IN TIME
All prescription medications must be the bottle issued by the pharmacy/doctor. If your
child arrives without their medication in the proper container, they will not be permitted to
attend camp
PLEASE REMEMBER TO LABEL EVERYTHING
This institution is an equal opportunity provider
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on
the basis of race, color, national origin, sex, age, or disability.
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2014 RESIDENT CAMP YOUTH REGISTRATION
To be filled out by parent or legal guardian
Child’s Last Name:
Child’s First_________________________
M.____
Parent(s) Name:
Home Phone: (
)
____________________
Cell Phone: (
Address:
APT. #
City:
Gender:
)_____________________________________
State:
Birth date:
Age:
Zip:
Dates Attending Camp: ___________________
My child wishes to bunk with*: __________________
School Grade:
* (must be same age group and gender)
Ethnicity/Race: Furnishing this information is required; it is desired
only for statistical purposes. Responses will not affect the applicant's
qualification to participate.
School Child attends:
Email Address:
How did you hear about our program?
___Camp Brochure ___Internet _____Camp Flyer
___Friend
___Other:
Will your child be celebrating a birthday with us? __________
Will your child be riding the bus?________(Aloha Camp Only)
Persons authorized to pick up my child:
____________________________________________________________
_________________
___
______________________________
Persons NOT authorized to pick up my child:
____________________________________________________________
__ White
__ Black/African American
__ Asian
__ American Indian or Alaska Native
__ Asian AND White
__ Native Hawaiian or Other Pacific Islander
__ American Indian or Alaska Native AND White
__ Black/African American AND White
__ American Indian/Alaska Native AND Black/African American
__ Other:
Hispanic/Latino Ethnicity ___Yes ___No
___ Mexican/Chicano
___ Puerto Rican
___ Cuban
___ Other Hispanic/Latino
Parent/Guardian Information
_____________________________________________
Name_____________________________________ Gender: __________Home Phone (if different from child): ______________________
__________
Employer’s Name:_____________________________________ Work Phone:________________________________Ext._____________
Cell Phone:_______________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Name_____________________________________ Gender: __________Home Phone (if different from child): ______________________
Employer’s Name:_____________________________________ Work Phone:________________________________Ext._____________
Cell Phone:_______________________________________________________
Custodial Care Information
____ Mother Only
____ Both Parents
_____ Father Only
_____ Other
Emergency Contacts – Other than parents/guardians
Name:____________________________________________________________________________________________________
Address:______________________________________________________City_________________________Zip:_________________
Phone Number:________________________ Other_____________________________
Name:___________________________________________________________________
Address:______________________________________________________City_________________________Zip:_________________
__
Phone Number: Home(_______)__________________________ Cell (________)_______________________________
PARENTAL/LEGAL GUARDIAN PERMISSION
I grant permission for my child or if over the age of 18 years accept to participate in all activities and camp programs, included but not
limited to ropes course, out-of-camp trips by van, bus or other designated vehicles, understanding that appropriate supervision is
provided under the State of California requirements for residential camp programs. I also understand that during my child’s
participation at Camp Fire Inland Southern California Council Camp Nawakwa, s/he/I may be exposed to a variety of risks and hazards,
foreseen or unforeseen, which cannot be eliminated without fundamentally altering the unique character of the program. Those
hazards include, but are not limited to, hiking/walking/running outside; snakes, insects, and large-animals; sunburn and heatstroke,
dehydration, hypothermia and other mild or serious conditions or injuries; falling and rolling rock; drowning; lightning and
unpredictable forces of nature (including weather that may change to extreme conditions without notice), etc. As a condition of my
child’s participation in the Program, I acknowledge that participation is entirely voluntary, and I agree to assume full responsibility for
the risks that participation may entail. I voluntarily agree to release, indemnify, and hold harmless Camp Fire Inland Southern
California Council, its officers, directors, agents and employees, to the fullest extent permitted under the law. I understand that this
release covers all liabilities, charges, expenses and costs on account of or by reason of any such injuries, claims, actions, or other legal
proceedings however occurring or damages growing out of the same. The authorization shall remain effective throughout the entire
camp session(s) the child attends unless sooner revoked in writing delivered to said agent(s). This authorization is given pursuant to
the provisions of Section 25.8 of the Civil Code of California.
Camp Fire Inland Southern California is not responsible for lost, stolen or damaged articles. I authorize Camp Fire Inland Southern
California, to have and use photographs, slides and/or video of my child/myself listed on this form for marketing and/or advertising
purposes (only), and I hereby consent to and authorize such use without seeking remuneration.
Camp Fire Inland Southern California has strict guidelines on how staff uses their personal social media sites with regard to their
employment. Camp attendees who are minors are not permitted to have contact with adult staff outside of camp including social
network sites unless they have written permission from their parent or guardian.
I HAVE READ THIS AGREEMENT. I FULLY UNDERSTAND IT AND AGREE TO BE LEGALLY BOUND BY IT
If participant is under the Age of 18 years a parent or guardian signature is required
Parent/Guardian Name: __________________________ Contact Number:_______________
Address:___________________________________ City:______________ Zip:___________
Signature: ________________________Date:_____________
Participant Name: _______________________________ Signature: ________________________ Date: _________
Camp Fire Inland Southern California
9037 Arrow Route, Suite 140
Rancho Cucamonga, CA 91730
(909) 466-5878
(909) 483-5042 fax
This institution is an equal opportunity provider
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, age, or disability.
CAMP FIRE INLAND SOUTHERN CALIFORNIA
HEALTH HISTORY FORM FOR CAMPERS/STAFF ATTENDING CAMP NAWAKWA
Name ________________________________________Birth Date_________________Age at camp__________
Last
First
mm/dd/yyyy
Home Address_______________________________________________________________________________
Street Address
Gender:
Male
City
Zip
Female
Custodial parent/guardian__________________________________ Phone___________Cell phone__________
Home Address (if different from above)___________________________________________________________
Business Address_____________________________________________________________________________
Second Parent or guardian emergency contact______________________________________________________
Address____________________________________________ Phone______________ Cell Phone___________
Insurance Information
Is the participant covered by family medical/hospital insurance?
Yes
No
If so, indicate carrier or plan name_____________ ___________________________ Group #________________
Carrier address_______________________________________________________________________________
Name of insured___________________________________________Relationship to participant______________
Insurance ID number________________________________________
Important – this box must be complete for attendance to Camp Nawakwa
Permission to provide necessary treatment or Emergency Care:
I hereby give permission to the medical personnel selected by
the camp director to order X-rays, routine tests, treatment; to
release any records necessary for insurance purposes; and to
provide or arrange necessary related transportation for me/or
my child. In the event I cannot be reached in an emergency,
I hereby give permission to the physician
selected by the camp director to secure and administer
treatment, including hospitalization, for the person
named above. This completed form may be photocopied for trips out of camp.
Signature of parent or guardian or adulamper/staffer______________________________________________________
Date___________________________
Health History
The following information must be filled in by the parent/guardian, adult camper or staff member. This information provides camp
health care personnel the background to provide appropriate care. Provide complete information so that the camp can be aware of
the needs of this participant.
Is this child “mentally or physically challenged”?
information.
_________
If yes, please attach a page providing additional
List any activities in which you DO NOT want your child to participate:
Archery_____Canoeing_____Hiking_____Swimming_____Wall Climbing_____
ALLERGIES (List all known)
________________________
Describe reaction and management of the reaction
_______________________________________________________________________
Food Allergies (List)
________________________
_______________________________________________________________________
Other allergies (list) - include insect stings, hay fever, asthma, animal dander, etc.
________________________ _______________________________________________________________________
MEDICATIONS BEING TAKEN (Please list ALL medications-including over-the-counter or nonprescription drugs taken
routinely. Camper should bring enough medication to last the entire time at camp. Keep in the original packaging/bottle that
identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and the frequency of
administration.
[ ] This person takes NO medications on a routine basis.
[ ] This person takes medications as follows:
Med #1____________________Dosage_____________Specific times taken each day____________________________
Reason for taking__________________________________________________________________________________
Med #2____________________Dosage_____________Specific times taken each day___________________________
Reason for taking__________________________________________________________________________________
Restrictions - The following restrictions apply to this individual:
Dietary: [ ] Does not eat red meat [ ]Does not eat pork
[ ] Does not eat poultry
[ ]Does not eat seafood
[ ] Does not eat eggs
[ ] Does not eat dairy products
[ ] Other (describe)__________________________________________________________________________________
Explain any restrictions to activity (e.g. what cannot be done, what adaptations or limitations are necessary)
_________________________________________________________________________________________________
Does participant experience any of the following: [ ] sleepwalking [ ] other sleep disturbances [ ] restlessness
[ ] nightmares [ ] bed wetting [ ] fainting [ ] convulsions [ ] constipation [ ] stomach upsets [ ] emotional problems
[ ] asthma [ ] chest pains after exercise [ ] frequent headaches [ ] seizures [ ] ear infections
Please explain_____________________________________________________________________________________
Give year of last immunization or booster against: DTP_____ Varicella_____ MMR______ Polio____ HIB_________
Hep.B_____ Hep. A_______ Tetanus__________ Other_________________________________________________
Which of the following has participant had? [ ] Measles [ ] German Measles [ ] Chickenpox [ ] Mumps
[ ] Hepatitis [ ] Others______________________________________________________________________________
Name of Family Physician _______________________________________________________Phone_______________
Parent/Guardian Authorization: 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 except as noted.
Child/Staff Name_________________________________________
Signed__________________________ Print Name______________________________ Date_________________
This institution is an equal opportunity provider
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, age, or disability.
CAMP FIRE CAMP NAWAKWA INLAND SOUTHERN CALIFORNIA
9037 Arrow Route, Suite 140, Rancho Cucamonga, CA 91730
CAMP FIRE CAMP NAWAKWA CAMPER’S PLEDGE & CODE OF CONDUCT
DURING MY STAY AT CAMP, I PLEDGE…
1. That I will make every effort to get along with my counselors and fellow campers, knowing that this will help us all have
more fun.
2. That I will follow all the rules of Camp Nawakwa as explained to me by my counselors and other staff members.
3. That I will stay with my group or my designated buddies at all times, and never stray from the group without permission.
4. That I will immediately inform the nearest staff member if I am injured or if I become ill. Staying healthy is an
important part of a fun camp experience.
5. That I will not bring (or acquire) drugs, alcohol, firearms, pocket knives or sharp objects, any controlled substance, or
items of value to camp. The camp expects all campers to abide by the law as well as camp rules for safety and fun.
6. That I will not pick fights with any other campers, camp staff. Gossiping and spreading rumors is strictly against the
rules and there is zero tolerance for such behavior.
RULES FOR CAMPERS TO FOLLOW DURING THEIR CAMP STAY
1. Walk at all times in camp and play in assigned areas only.
2. The Ropes Course is not a play area. Keep off at all times unless accompanied by the program specialist.
3. Obey all safety rules and use equipment correctly according to the Camp Fire rules on cookouts and during program
activities.
4. Playing with sticks, rock throwing, and tree climbing are not allowed.
5. Keep hands, feet and objects to yourself. This means karate chops and kicks are not allowed. Playing tricks on others is
not permitted.
6. Chewing gum is not permitted in camp.
7. Use the restroom materials and facilities for intended purposes only. Play is not allowed in the bathroom.
8. Teasing and use of profanity or crude (meaning not acceptable around your kitchen table) and hurtful words are
unacceptable.
9. Disturbing other people’s belongings is not allowed.
10. Show consideration for other campers and adults at all times.
11. Stealing is grounds for immediate expulsion from camp.
12. Cell phones, toys, electronics and skateboards or bikes are not allowed in camp. We are not responsible for any items
that arrive and are then damaged.
13. Sports equipment, gloves, etc. are not allowed to be brought to camp.
14. You must wear shoes and socks – NO OPEN TOE SHOES!
15. Campers are asked to tell the truth at all times.
I UNDERSTAND THAT…
1.
2.
3.
Staff members have my best interests at heart and want me to have a good time, so I will abide by their decisions.
If there is a misunderstanding that cannot be cleared up by my counselor, I will be able to talk with the camp director,
assistant director, or executive director.
My failure to follow these guidelines and others necessary for a safe and happy experience for everyone may lead to my
being sent home at my parent’s expense and their transportation.
THESE RULES ARE FOR THE PROTECTION, HEALTH AND SAFETY OF ALL PEOPLE IN CAMP. EVERYONE IS EXPECTED TO
ADHERE TO THEM. IF, AFTER A NUMBER OF WARNINGS AND CONSULTATION WITH THE CAMP DIRECTOR, THE CHILD DOES
NOT MEET THESE STANDARDS, HE/SHE WILL BE EXPELLED FROM CAMP, THE PARENT/GUARDIAN WILL BE CALLED AND
ASKED FOR THE IMMEDIATE REMOVAL OF THEIR CHILD FROM CAMP.
PARENTS:
Please note that by signing this binding contract, you are also agreeing with the rules of Camp Nawakwa as well as the
consequences. Should your child need to be picked up from camp due to violations of this contract, you are responsible for
picking your child up from camp.
CAMPER’S SIGNATURE: __________________________ DATE:_______________
PARENT’S SIGNATURE: __________________________ DATE:_______________
This institution is an equal opportunity provider
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, age, or disability.
CALIFORNIA DEPARTMENT OF EDUCATION
NUTRITION SERVICES DIVISION
SUMMER FOOD SERVICE PROGRAM
(REV. 10/13)
1 OF 2
SUMMER FOOD SERVICE PROGRAM
LETTER TO PARENTS
Dear Parent/Guardian:
Providing nutritious meals to children at a reasonable cost is an increasing growing challenge.
To assist our program in offsetting the costs for meals served to the children, we receive federal
reimbursement funds through the Summer Food Service Program (SFSP). This reimbursement allows us
to afford and offer better service to children. Please complete, sign, and return the attached confidential
Income Eligibility Form for Camps and Enrolled Sites as soon as possible.
Instructions for completing the eligibility information are on the reverse side of the form. Please contact
Camp Fire if you have questions or need assistance in completing form.
The chart below is used to determine the children’s/child’s eligibility to receive SFSP meals. If the
children’s/child’s family household income is at or below the dollar amount in the chart, the children/child
are/is eligible to receive free Summer Food Service Program meals.
Please compete the attached form and return it to: Camp Fire, 9037 Arrow Route, Suite 140, Rancho
Cucamonga, CA 91730
Thank you for your participation and cooperation.
THIS SCALE DOES NOT APPLY TO HOUSEHOLDS THAT RECEIVE CALFRESH, CALWORKS, FOOD
DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR), WORKFORCE INVESTMENT ACT
(WIA), OR KIN-GAP BENEFITS. THOSE CHILDREN ARE AUTOMATICALLY ELIGIBLE FOR FREE
MEAL BENEFITS.
Income Eligibility Guidelines
Effective July 1, 2013 to June 30, 2014
HOUSEHOLD
SIZE*
ANNUALLY
MONTHLY
TWICE PER
MONTH
EVERY TWO
WEEKS
WEEKLY
1
$ 21,257
$ 1,772
$ 886
$ 818
$ 409
2
$ 28,694
$ 2,392
$ 1,196
$ 1,104
$ 552
3
$ 36,131
$ 3,011
$ 1,506
$ 1,390
$ 695
4
$ 43,568
$ 3,631
$ 1,816
$ 1,676
$ 838
5
$ 51,005
$ 4,251
$ 2,126
$ 1,962
$ 981
6
$ 58,442
$ 4,871
$ 2,436
$ 2,248
$ 1,124
7
$ 65,879
$ 5,490
$ 2,745
$ 2,534
$ 1,267
8
$ 73,316
$ 6,110
$ 3,055
$ 2,820
$ 1,410
$ 7,437
$ 620
$ 310
$ 287
$ 144
For each
additional family
member, add:
* A household of one means a child who is his or her sole support. Foster children are one-member
households only if the welfare or the placement agency maintains legal responsibility for the child.
Household is synonymous with family and means a group of related or unrelated individuals who are
not residents of an institution or boarding house, but who are living as one economic unit sharing
housing and all significant income and expenses.
CALIFORNIA DEPARTMENT OF EDUCATION
NUTRITION SERVICES DIVISION
SUMMER FOOD SERVICE PROGRAM
(REV. 10/13)
2 OF 2
Camp and Enrolled Sites
Income Eligibility Form
Check a box to identify a foster child (the legal
responsibility of a welfare agency or court).
1. CHILD INFORMATION
(List names of all enrolled children)
Last
First
M.I.
If all children listed below are foster children, go to #4
to sign this form.
1.
2.
3.
4.
2. CATEGORICAL EILIGIBILITY: If you are getting CalFresh, CalWORKs, Food Distribution Program on
Indian Reservations (FDPIR), or Kin-Gap benefits for your child, list the case number. If your child participates in
the Workforce Investment Act (WIA) check the box. DO NOT complete #3. Go to #4.
CalFresh Case Number:
CalWORKs Case Number:
FDPIR Case Number:
Kin-GAP:
WIA:
3. HOUSEHOLD INCOME: Complete this section if you DID NOT complete #2. List all household members and
all income. Go To #4.
Enter Gross Income and how often it is received (e.g., weekly, every 2 weeks, twice a month, monthly, or annually)
NAMES OF HOUSEHOLD MEMBERS
(INCLUDE THE CHILDREN LISTED ABOVE)
EARNINGS
FROM WORK BEFORE
DEDUCTIONS
PAYMENTS
FROM PENSIONS,
RETIREMENT,
SOCIAL SECURITY
CHILD SUPPORT,
ALIMONY
EARNINGS
FROM ANY
OTHER
INCOME
Amount / How Often
Amount / How Often
Amount / How Often
Amount / How Often
1.
$
/
$
/
$
/
$
/
2.
$
/
$
/
$
/
$
/
3.
$
/
$
/
$
/
$
/
4.
$
/
$
/
$
/
$
/
5.
$
/
$
/
$
/
$
/
6.
$
/
$
/
$
/
$
/
7.
$
/
$
/
$
/
$
/
8.
$
/
$
/
$
/
$
/
CALIFORNIA DEPARTMENT OF EDUCATION
NUTRITION SERVICES DIVISION
SUMMER FOOD SERVICE PROGRAM
(REV. 10/13)
2 OF 2
4. LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (SSN) AND SIGNATURE:
PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that
the CalFresh, CalWORKs, FDPIR, Kin-GAP, or other eligible program case number is current, correct, or that all
income is reported. I understand that this information is provided for the receipt of federal funds; that agency
officials may verify the information on the Income Eligibility Form for Camp and Enrolled Sites and that the
deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal
laws.
Printed Name:
Last Four Digits of SSN:
Check here if no SSN
Signature of Adult:
Date:
Privacy Act Statement: Unless you list the child's CalFresh, CalWORKs, FDPIR, WIA or Kin-GAP case number,
Section 9 of the National School Lunch Act (NSLA) requires that you include the last four digits of the SSN for the
household member signing the form, or indicate that the household member signing the form does not have a SSN.
You do not have to list the last four digits of a SSN, but if they are not listed, or the “Check here if no SSN” is not
marked, we cannot approve your child for free or reduced price meals. The last four digits of the SSN may be used
to identify the household member in verifying the correctness of the information stated on the form. This may
include program reviews, audits and investigations, and may include contacting employers to determine income,
contacting a CalFresh, CalWORKs, FDPIR, or Kin-GAP office to determine current certification for CalFresh,
CalWORKs, FDPIR, or Kin-GAP benefits, contacting the state employment security office to determine the amount
of benefits received, and checking the documentation produced by the household member to prove the amount of
income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if
incorrect information is reported. The last four digits of the SSN may also be disclosed to programs as authorized
under the NSLA and the Child Nutrition Act, the Comptroller General of the United States, and law enforcement
officials for the purpose of investigating violations of certain federal, state, and local education, and health and
nutrition programs.
5. RACIAL/ETHNIC IDENTITY: You are not required to answer these questions. If you choose to do so, please
mark one or more of the following racial identities:
American Indian or Alaska Native
Asia
Black or African American
Native Hawaiian or Other Pacific Islander
White
Please mark one of the following ethnic identities:
Hispanic or Latino
Not Hispanic or Latino
The U.S. Department of Agriculture prohibits discrimination against its customers, employee, and applications for employment
on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political
beliefs, material status, familial or parental status, sexual orientation, or all of part of an individual’s income is derived from any
public assistance program, or protected genetic information in employment of in any program or activity conducted or funded
by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaints of discrimination, complete the USDA Program Discrimination Complaint
Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html , or at any USDA office, or call (866) 632-9992 to
request the form. You may also write a letter containing all of the information requested in the form. Send your completed
complaint form or letter to us by mail at U.S. department of Agriculture, Director, Office of Adjudications, 1400 Independence
Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected].
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA thought the Federal Relay Service at
(800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
For Agency Use Only
CATEGORICAL ELIGIBILITY
CalFresh/CalWORKs/FDPIR/Kin-GAP household categorically eligible:
Foster child automatically eligible:
Yes
Yes
No
No
INCOME ELIGIBILITY Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12
Total income:
Eligibility classification:
Household size:
Eligible
Not Eligible
Determining official (print name):
Determining office signature:
Certification Date:
CALIFORNIA DEPARTMENT OF EDUCATION
NUTRITION SERVICES DIVISION
SUMMER FOOD SERVICE PROGRAM
(REV. 10/13)
HOW TO COMPLETE THE INCOME ELIGIBILITY FORM
Using the instructions below, please complete, sign, and return the Income Eligibility Form to: Camp Fire Inland Southern
California, 9037 Arrow Route, Suite 140, Rancho Cucamonga, CA 91730
If you need help, call: 909-466-5878
1.
CHILD INFORMATION:
a) Print your child’s name.
b) Check a box in the right column to identify a foster child.
2.
CATEGORICAL ELIGIBILITY: Complete this section and sign the form in section #4.
a) List your current CalFresh, CalWORKs, FDPIR or Kin-GAP case number(s) for your child(ren).
b) Sign the form in section #4. An adult household member must sign. You do not have to list a SSN.
3.
HOUSEHOLD INCOME: Complete this section if the child does not qualify as Categorical Eligibility and sign the form in
section #4.
Write the names of everyone in your household even if they do not have an income. Include yourself, your spouse, the
child you are applying for, and all other household members. If your household includes any foster children formally
placed by a state child welfare agency or a court, you may choose to include the child(ren) in this list.
a) Write the amount of income each person received last month before taxes or anything else was taken out and
where it came from, such as earnings, CalWORKs, pensions, and other income (see examples below for types of
income to report). If you have chosen to include any foster children in your care, only the personal use
income is to be listed. Foster payments you receive from the placing agency for the care of the child do not
need to be reported. Each income amount should be entered in the appropriate column on the form. If any amount
last month was more or less than usual, write that person’s usual monthly income.
b) If anyone is self-employed, write the amount of income that person earns from self-employment. Please call the
number listed at the top of the form if you need help.
c) Sign the form and include the last four digits of your SSN in section #4. If you do not have a SSN, check the box
“Check here if no SSN.”
4.
LAST FOUR DIGITS OF SSN AND SIGNATURE:
a) The form must have a signature of an adult household member.
b) The adult household member who signs the statement must include the last four digits of his/her SSN. If he/she
does not have a SSN, check the box “Check here if no SSN”. The last four digits of your SSN is not needed if you
listed a CalFresh, CalWORKs, FDPIR, or Kin-GAP case number.
5.
RACIAL/ETHNIC IDENTITY: You are not required to answer this question to get meal benefits, but completion of this
information will help ensure that everyone is treated fairly.
INCOME TO REPORT
Earnings from Work:
Wages/salaries/tips
Strike benefits
Unemployment compensation
Worker’s compensation
Net income from self-employment
Public assistance payments
CalWORKs payments
Alimony/child support payments
Pensions/Retirement/Social Security
Pensions
Supplemental security income
Retirement income
Veteran’s payments
Social Security
Other Monthly Income
Disability benefits
Cash withdrawn from savings
Interest dividends
Income from estates/trusts/investments
Regular contributions from persons not
living in the household
Net royalties/annuities/net rental
income
Military allowance for off-base housing
Any other income
“FOR AGENCY USE ONLY” SECTION
The sponsor must complete this section to indicate whether the enrolled participant is or is not eligible to receive meals.
Failure to complete this final step could cause loss of reimbursement.
CALIFORNIA DEPARTMENT OF EDUCATION
NUTRITION SERVICES DIVISION
SUMMER FOOD SERVICE PROGRAM
(REV. 10/13)
DESCRIPTION OF RACIAL AND ETHNIC CATEGORIES
The federal government has established the following five racial categories and one ethnic
category:
RACE:
American Indian or Alaska Native–A person having origins in any of the original peoples of
North and South America (including Central America), and who maintain tribal affiliation or
community attachment.
Asian–A person having origins in any of the original peoples of the Far East, Southeast Asia, or
the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, The Philippine Islands, Thailand, and Vietnam.
Black or African American–A person having origins in any of the black racial groups of Africa.
Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American."
Native Hawaiian or Other Pacific Islander–A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White–A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
ETHNICITY:
Hispanic or Latino–A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race. The term, "Spanish origin" can be used in
addition to "Hispanic or Latino."
Not Hispanic or Latino
CAMP NAWAKWA PACKING LIST & MISCELLANEOUS INFORMATION
WHAT TO PACK:
Remember OLD CLOTHES are best
Shorts - comfortable for hiking
Underwear
Closed-toe shoes
Socks
Shirts (long and Short sleeved) 1 for each day of stay
Long pants
Warm sweater, jacket or coat
Swim suit. One-piece bathing suits are required for girls. If not available, please
send non-white shirt to wear over top.
Wash cloth and towels (1 swim and 1 bath).
Warm sleeping bag & pillow
Old, warm, blanket (for sleeping and for sitting around the campfire at night)
Soap, comb, brush, shampoo, toothbrush (in a container), toothpaste & other
personal hygiene items
Chapped lip protection
Rain jacket
Refillable water bottle or canteen
Mosquito repellant and sunscreen
Flashlight & extra batteries (be sure to label all equipment with child’s name!)
Bag for dirty clothes (a pillow case will do just fine)
Theme Day items: Make sure to check which session your attending
A favorite stuffed animal (for our stuffed animal contest)
OPTIONAL: Camera, day/backpack, autograph book, song book, story book, compass, hiking
boots, hat, sunglasses, alarm clock, slippers, sandals, sweatshirt and sweatpants.
CAMPER MAY NOT BRING THE FOLLOWING: Food or snacks, cell/smart phones,
radios, MP3 players, iPods, electronic games, expensive watches, jewelry, gum, candy, money,
pocket knives or sharp objects, or other valuables. Such items will be confiscated and then
returned at the end of camp.
MEDICATION: Make sure your child brings their prescribed medications and that they have
enough to last their time at camp. Any child that does not bring their medication or enough
supplies will be sent home, no exceptions.
MAKE SURE ALL CLOTHES AND BELONGINGS ARE LABELED
Camp Fire will NOT be responsible for any lost or broken items.
This institution is an equal opportunity provider
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited
from discriminating on the basis of race, color, national origin, sex, age, or disability.