Thank you for submitting your child`s online application for CCFA`s

Dear Parent/Guardian:
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Thank you for submitting your child’s online application for CCFA’s Camp Oasis of Washington: June 26 – July 2
nd
2016.
In order to complete the application process, you must now print and submit signed versions of all of the forms that are
included in the following pages of this document:
(1) General Authorization & Release Form
(2) GI Medical Professional Form
(3) Behavioral Support Form (only if applicable)
(4) Severe Allergy Action Plan (only if applicable)
(5) Leaders in Training (LIT) Application (only if applicable)
As part of your complete application, you must also submit a:
(1) Signed Medication List (sent via email upon submission of your online application)
(2) $400 Attendance Fee (unless already paid by credit card or awaiting pending status of scholarship application)
Please make checks payable to CCFA or call (646) 943 – 7480 to pay by phone. You can pay in installments.
(3) Photograph of Camper (clearly displaying child’s face)
(4) Copy of Insurance Card (both sides)
(5) Copy of Pharmacy Card (only if applicable)
(6) Copy of Immunization Record (only if not submitted online)
For your reference, a checklist of these required application items is provided on the next page.
In order for your child to be considered for camp, ALL of this information, including full payment, must be sent in no later
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than May 27 , 2016. An application is not considered complete until ALL items are received. Although payment is not
needed to review your child’s application, it is still required in order for your child to attend camp and must be submitted
no later than the application deadline.
Once all of the required items have been received, our Camp Director and Medical Director will review the COMPLETE
application, and then we will let you know if camp will be able to accommodate your child.
Because of this careful review process, we will not be able to consider applications received after the deadline.
Additionally, applications will be considered on a first come complete, first served basis. Space is limited so we
strongly encourage you to submit your complete application as soon as possible.
Thanks again for your interest in CCFA Camp Oasis!
For questions regarding the application process, attendance fee, and scholarship program - please contact National
Camp Manager, Daniel Marinoni: (646) 943 – 7480 or [email protected].
For questions regarding the camp program (activities, amenities, menu, schedule, etc.) and your child’s acceptance please contact Regional Education & Support Manager, Kathleen Newbould Waite: (425) 451 – 8455 x 6 or
[email protected].
Sincerely,
Your CCFA Camp Oasis Leadership Team
Camper’s Name: ______________________________________________________
D.O.B.: _____________________
2016 CAMPER APPLICATION CHECKLIST & CLARIFICATIONS
The following is a list of the additional hard copy forms required as part of every application.
Required Application Forms
Page of this Packet
To be completed and signed by?
NA, came by email
Parent/Guardian AND GI MD or NP
General Authorization & Release Form
3
Parent/Guardian
YMCA Camp Colman Liability & Release Form
4
Parent/Guardian
GI Medical Professional Form
6
GI MD or NP
Behavioral Support Form (if applicable)
7
Mental Health Specialist/ Prescribing MD
Severe Allergy Action Plan (if applicable)
8
Allergist/ Prescribing MD
LIT Application (if applicable)
10
LIT AND Parent/Guardian
Current Medication List
Application Attachments: The following is a list of the additional attachments required as part of every application.
Payment of $400 (unless already paid by credit card or awaiting pending status of scholarship application)
Please make checks payable to CCFA or call (646) 943 – 7480 to pay by phone. You can pay in installments.
Photograph of Camper (clearly displaying the child’s face)
Copy of Insurance Card (both sides)
Copy of Pharmacy Card (only if applicable)
Copy of Immunization Record (only if information was not relayed in online application)
CLARIFICATIONS ON HARD COPY APPLICATION FORMS:

Current Medication List
o




This list was sent in the body of the email you received upon applying, and reflects the information you supplied in the online
application. It must be reviewed and signed by you and your child’s GI physician or nurse practitioner. Any changes that are
written in must be initialed by you and your child’s GI physician or nurse practitioner. This list must be signed and submitted
even if your child is not currently taking any medication.
Medical Professional Form
o
Camp policy requires that every camper submit a record of having a physical exam within 12 months of camp. Therefore,
your child’s GI physician or nurse practitioner must complete this form based on a visit that has occurred since August 2015.
o
If your child is not currently seeing a GI, his/her pediatrician should complete the form instead.
Immunization Record
o
Camp policy requires that your child’s immunizations be up-to-date. If you are uncertain of your child’s status, please check
with his/her doctor, and arrange to have any necessary vaccines given. CDC guidelines are included.
o
If your child has not been vaccinated due to medical, personal, or religious reasons, you will need to request an Immunization
Release Form from CCFA, and include it as part of your child’s application. Email [email protected] to request this form.
Behavioral Support Form
o
This form must be submitted if your child (1) has a behavioral, emotional, or mental health diagnosis, (2) has seen a mental
health professional (i.e. therapist, social worker) in the past 12 months, AND/OR, (3) is currently taking a mood altering
medication for ANY reason.
o
If your child has seen a mental health professional in the past 12 months, that person should complete the form. If your child
has not seen a mental health professional in the past 12 months, the physician who prescribed the medication and/or
diagnosed the behavioral, emotional, or mental health condition should complete the form.
Severe Allergy Action Plan
o
This form must be completed by your child’s Allergist if your child requires epinephrine when exposed to an allergen.
o
If your child is not currently seeing an Allergist, his/her pediatrician should complete the form instead.
SUBMISSION INSTRUCTIONS:
Be sure that all of the attached forms are COMPLETE and have been SIGNED by the appropriate people. Then return them, along
with the other required attachments (e.g., copy of insurance card, photo, etc.) and payment, to the CCFA National Office no later than
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May 27 , 2016. Information on how to submit the forms have been included within this packet and can be found at the bottom of every
form. Reminder, applications are considered in the order in which they are received, based on the date the application is fully complete.
Some camps are unable to accommodate all applicants so please submit all signed paperwork and payment as soon as possible.
Camp Oasis of Washington
Submit forms to: CCFA, Camp Oasis - 733 Third Avenue, Suite 510 – New York, NY 10017 / Email: [email protected] / Fax: (212) 779 – 4098
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Camper’s Name: ______________________________________________________
D.O.B.: _____________________
.
2016 GENERAL AUTHORIZATION & RELEASE FORM
Name of child who will be a camper at CCFA Camp Oasis:
_______ ___ hereinafter referred to as the "Applicant."
(Write the child’s name above)
Note: Please read the following information carefully. Every item on this page must be understood before signing.
I certify that I am the parent or legal guardian of the above named Applicant.
I certify that I have provided accurate information in all parts of the application.
I understand that Applicant will be participating in many physical activities at CCFA Camp Oasis and its host site location (hereinafter
referred to as the "Camp"), and I give permission for Applicant to engage in all activities except as I have noted on his/her application.
I authorize Camp to release Applicant's records to Camp medical and non-medical staff and to third parties as necessary, for the
purposes of Applicant's medical treatment, the non-medical care of Applicant, for the purposes of a referral, billing, or insurance
purposes, as deemed necessary by Camp staff.
I authorize Camp medical staff to provide Applicant with medical care and medication according to the instructions provided in the
Applicant’s forms, or, for issues not detailed in the forms, as deemed necessary by Camp medical staff.
I authorize Camp medical staff to contact any of Applicant's physicians and mental health providers listed on Applicant’s forms, to
obtain any records necessary for treatment, referral, billing, or insurance purposes.
I authorize Camp medical staff to consent to any emergency medical care or treatment, including the dispensing of medicine,
examinations, immunizations, x-rays, tests, dental care, anesthetics, medical or surgical diagnosis or treatments, and hospital care, to
be rendered to the Applicant as deemed necessary by the Camp medical staff.
I give consent for any transportation deemed necessary or appropriate, at the discretion of the Camp, in connection with the medical
treatment of the Applicant.
I assume financial responsibility for any and all medical and other expenses incurred for or on behalf of Applicant while at Camp or
offsite.
I authorize Camp to provide transportation to the Applicant, as needed, while the Applicant heads to, attends, and leaves Camp. I
release and hold harmless the Crohn’s & Colitis Foundation of America and Camp from all claims, damages and liabilities that may
result, directly or indirectly, from any injury that Applicant may suffer during such transportation.
I give permission to Camp to use Applicant's name, photographs, and other reproduction(s) and likenesses in connection with
activities, publications, and media publicity of Camp and the Crohn’s & Colitis Foundation of America.
I agree to allow Applicant’s name, mailing address, telephone number, and email address to be included in a CCFA Camp Oasis
Directory, which may be distributed to all campers from his/her session after camp has ended.
I agree to be responsible for monitoring Applicant’s contact with all Camp staff and campers once Camp has ended, and for ensuring
that Applicant does not post Camp photos or images on social networking websites without CCFA approval.
I agree to be responsible for the pick-up of Applicant if Camp decides to send him/her home due to illness, behavioral/emotional
issues, or any serious violation of Camp rules. I agree that Camp shall be the sole judge of what constitutes a serious violation.
I understand that in order for Applicant to attend Camp, I must give up any rights to hold Camp liable for any injury or damage that
Applicant may suffer while attending Camp or participating in Camp’s activities.
I voluntarily release and hold harmless the Crohn’s & Colitis Foundation of America, its officers and directors, local CCFA chapters,
Camp, and each of their officers, agents, trustees, employees, and volunteers from any and all liability resulting from or arising out of
Applicant traveling to/at/from and attending Camp or participating in Camp’s activities.
I have read the above information carefully, and I have fully understood each item. I understand that if I have any questions regarding
anything contained in this Release, I may call the CCFA Camp Office.
This Release has been executed as of (today’s date): ___________________________________
Parent/Guardian Name: ____________________________________________________________
Parent/Guardian Signature: ________________________________________________________
NOTE: If you do NOT want your child to be included in the CCFA Camp Oasis Directory, please sign here instead:
Camp Oasis of Washington
Submit forms to: CCFA, Camp Oasis - 733 Third Avenue, Suite 510 – New York, NY 10017 / Email: [email protected] / Fax: (212) 779 – 4098
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YMCA Camp Colman
All participants of programs and events at Camp Colman must bring this signed Release of Liability &
Acknowledgment of Risk with them to Camp. Forms of participants under the age of 18 must be
signed by a parent or legal guardian.
Participant Name (Please Print): ______________________________________ Birthdate: ______________ Gender: _________________
Address: ______________________________________________ City: _____________________ State: _________ Zip: ___________________
Home Phone: (______) _____________ Email: __________________________________________________________________________________
If participant is under the age of 18, parent or guardian’s name (Please Print):______________________________________________________
___________________________________________________________________________________________________________________________________
Acknowledgment of Risk
I am aware that I will have the opportunity to participate in camp activities involving a degree of risk.
These activities may include warm ups, games involving running, group initiative problems, Giant
Swing, and other rigorous physical adventure activities. I also understand that being out-of-doors
for periods of time I may be exposed to wind, rain, and other natural elements, fire or wildfire. I may
have the opportunity to participate in camp-facilitated activities including: field and court games,
archery, row boats, arts and crafts and marine tank exploration. If doing a ropes/challenge course, I
understand that, wearing harnesses and helmets, I may be climbing trees, walking on cables and logs
that are suspended in the air. If participating in water activities, I understand that I may be exposed
to cold water, wind, rocky beaches, hypothermia, and possibility of drowning. I also understand that I
may be cooking out of doors, using stoves, and other kitchen materials. I understand that there is a
degree of physical and emotional risk associated with this type of activity. I am aware that
participation in these activities is by the choice of the individual and has inherent risks. I understand
that if I have high blood pressure or a cardiac condition I should consult my physician before
participating in high adventure activities. I also understand that if I am pregnant I should not
participate in high adventure activities. Recognizing that the camp will do its best to ensure a safe
experience, I understand that certain dangers or accidents may occur.
Release of Liability
I agree to release and indemnify the YMCA of Greater Seattle (its directors, officers, employees,
agents and volunteers, collectively “YMCA” from any loss, damage or cost incurred due to my
participation whether caused by the ordinary negligence of the YMCA releases or by any other
person. I assume full responsibility for the risk of such loss, liability, damage, injury or death.
Photo Release
I give permission for the YMCA (local, national, and international) to use, without limitation or
obligation, photographs or other media that may identify or include the image or voice of me or my
child to promote or interpret YMCA programs for any business purpose, including media coverage. I
waive all claims for any compensation for such use.
_______________________________________________________________________________________________
Participant’s Signature
__________________________
Date
_______________________________________________________________________________________________
Signature of Parent/Legal Guardian if participant is under 18 years old
__________________________
Date
Updated 12/10/2014
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Camp Oasis of Washington
Submit forms to: CCFA, Camp Oasis - 733 Third Avenue, Suite 510 - New York, NY 10017 / Email: [email protected] / Fax: (212) 779 - 4098
Camper’s Name: ______________________________________________________
D.O.B.: _____________________
Parent/Guardian Signature: _______________________________________________________
Letter to Healthcare Providers
Dear Healthcare Provider,
You are receiving this letter because one of your patients is applying to Camp Oasis, the Crohn’s & Colitis Foundation of
America’s (CCFA) coed, residential summer camp program for children with Crohn’s disease and ulcerative colitis. In
order to attend parents must complete an in depth application process to determine whether CCFA will be able to
accommodate their child while away at camp. The information you provide in the forms following this letter will help our
medical review team reach a decision so please answer all questions as accurately and with as much detail as possible.
Below is a list of the forms that must be submitted, and who or what is required to complete them. Thank you!


GI Medical Professional Form
o
Camp policy requires that every camper submit a record of having a physical exam within 12 months of camp.
Therefore, the child’s GI physician or nurse practitioner must complete the form based on a visit that has occurred since
August of 2015.
o
If the child is not currently seeing a GI, his/her pediatrician may complete the form instead.
Current Medication List
o
Must be reviewed and signed by both the parent and the child’s GI physician or nurse practitioner. Any changes that are
written in must be initialed by the parent and the child’s GI physician or nurse practitioner. This list must be signed and
submitted even if the child is not currently taking any medication.
o


Immunization Record – (can be submitted electronically by parent)
o
Camp policy requires that every child’s immunizations be up-to-date. Parents should check with their doctor, and
arrange to have any necessary vaccines given. CDC guidelines have been provided.
o
If the child has not been vaccinated due to medical, personal, or religious reasons, they will need to request an
Immunization Release Form from CCFA, and include it as part of their application.
Behavioral Support Form – (if applicable)
o
o

If the child is not currently seeing a GI, his/her pediatrician may complete the form instead.
This form must be completed by the child’s mental health professional if the child:

Has a behavioral, emotional, or mental health diagnosis.

Has seen a mental health professional (i.e. therapist, social worker) in the past 12 months for ANY reason.

Is currently taking a mood altering medication for ANY reason.
If the child is not currently seeing a mental health professional, the physician who prescribed the medication and/or
diagnosed the behavioral, emotional, or mental health condition should complete the form.
Severe Allergy Action Plan – (if applicable)
o
This form must be completed by the child’s Allergist if the child experiences anaphylaxis when exposed to an allergen.
o
If the child is not currently seeing an Allergist, his/her pediatrician may complete the form instead.
Submission Instructions
Parents are urged to submit all of their forms together. Therefore, these forms should be returned to the parent/guardian
to be submitted to CCFA’s National Office. If you are submitting all of the forms on their behalf, they can be faxed to (212)
779 – 4098 or emailed to [email protected]. If you have any questions, please contact Daniel Marinoni at (646) 943 – 7480
Thank you for your time!
Sincerely,
CCFA’s Camp Oasis Leadership Team
Camp Oasis of Washington
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Submit forms to: CCFA, Camp Oasis - 733 Third Avenue, Suite 510 – New York, NY 10017 / Email: [email protected] / Fax: (212) 779 – 4098
Camper’s Name: ______________________________________________________
D.O.B.: _____________________
2016 GI MEDICAL PROFESSIONAL FORM
MUST BE COMPLETED & SIGNED BY LICENSED GI PHYSICIAN OR NURSE PRACTITIONER
Date of Most Recent Exam: _______________________
IBD Diagnosis: __________________________________
Symptom(s) during a “flare”: ______________________________
Disease Extent/Location: __________________
Extraintestinal Manifestations: Check all that apply.
 Fevers (> 38 C or 100 F)
 Mouth sores
 Joints (arthritis/arthralgia)  Skin (E. nodosum/P. gangrenosum)
Eyes (uveitis)
 Headaches
 Sclerosing chol.
 Perianal disease (tag/fissure/fistula)
Allergies: ________________________________________________________________________________________
Is the child developmentally appropriate for his/her age? Y / N
If no, at what age does the child function: _______
Other Medical, Behavioral or Psychosocial Concerns:___________________________________________________
Significant Events/Surgeries (What/When): ____________________________________________________________
Please include the findings from the child’s most recent exam below.
Weight: ______________
Height: ______________
Abdominal Pain Intensity:
 Mild
 Form
 Semi
Type of Stools:
Normal
 Moderate
 Loose
Growth:
 Severe
 Blood
 Acute Weight Loss
 None
 Mucus
Frequency of Pain per Day: __________
 Nocturnal
Abnormal
 Chronic Growth Failure
Frequency of Stool per Day: _________
Comments
EENT
Neck
Lungs
Heart
Abdomen
Anus/Rectum
Muscular/Skeletal
Psych
Lymph
Neuro
Skin
Other
I understand that the above listed individual is seeking to participate in a special overnight camp for kids with inflammatory bowel disease,
sponsored by the Crohn’s & Colitis Foundation of America (CCFA), which provides a Medical Team consisting of physician(s) (including a
gastroenterologist), nurses, and a mental health professional who will be on-site and on-call 24-hours a day to provide basic care during camp.
I understand that this camp program will provide the above listed individual with the opportunity to participate in supervised activities which
may include but are not limited to pool/swimming, horseback riding, high ropes course, and organic gardening.
I believe CCFA should
 ACCEPT or  DECLINE this applicant, based on this information and my work with this individual.
Comments/Limitations/Restrictions:__________________________________________________________________________
GI MD/ Nurse Practitioner Name: _________________________________________
Phone: ___________________________
GI MD/ Nurse Practitioner Signature: _______________________________________
Date: _____________________________
Camp Oasis of Washington
Submit forms to: CCFA, Camp Oasis - 733 Third Avenue, Suite 510 – New York, NY 10017 / Email: [email protected] / Fax: (212) 779 – 4098
6
Camper’s Name: ______________________________________________________
D.O.B.: _____________________
2016 BEHAVIORAL SUPPORT FORM
THIS FORM MUST BE SUBMITTED AS PART OF THE APPLICATION IF:
(1) Applicant has been diagnosed with a behavioral or mental health condition (e.g., ADD/ADHD, Anxiety, Depression, PTSD, OCD);
(2) Applicant has seen a mental health professional (e.g., social worker, psychologist, psychiatrist) in the past 12 months, AND/OR;
(3) Applicant has been prescribed or is currently taking a psychoactive medication for any reason.
THIS FORM MUST BE COMPLETED BY:
(1) Applicant’s mental health professional (social worker, psychologist, psychiatrist, etc.), if applicable, OR;
(2) The medical professional that prescribed the medication or diagnosed the behavioral, emotional, or mental health condition.
Name of Person Completing Form: __________________________________________________________________
Profession: ______________________________________
Relationship to Applicant: _____________________________
What initially prompted treatment?  family-initiated  PMD mandate  school referral
 other: __________________
When did treatment begin? ________________________________
How is patient currently seen?:  regularly  as needed
Date of Most Recent Visit: __________________________________
Number of Visits in Past 12 Months: ____________________
Most recent/current disposition of treatment & involvement with patient: _______________________________________________
Diagnosis/Reason for Treatment: ____________________________________________________________________
Date of Diagnosis (if formal DSM diagnosis): __________________
Essential Meds for Diagnosis: ________________________
Criteria met that led to diagnosis: _________________________________________________________________________________
Behavioral manifestations that may appear at camp & suggested ways to manage:
To your knowledge, is there or has there ever been concern about any of the following? (Check all that apply.):
 Passive or active suicidal ideation or plans
 Self-harm
 Impulse control
 Aggression
If any of these items are checked, please explain:
Due to camper volume, onsite mental health providers may not be able to carry out specialized treatment goals during
camp. Can this child function at camp with only basic care from the on-site mental health provider?
 YES  NO
If no, please explain:
I understand that the above listed individual is seeking to participate in a special overnight camp for kids with inflammatory bowel
disease, sponsored by the Crohn’s & Colitis Foundation of America (CCFA), which provides a Medical Team consisting of physician(s),
nurses, and a mental health professional who will be on-site and on-call 24-hours a day to provide basic care during camp.
I believe CCFA should
 ACCEPT or  DECLINE this applicant based on this understanding and my work with this individual.
Comments/limitations/restrictions: __________________________________________________________________
Provider Name: ________________________________________________________
Phone: ___________________________
Provider Signature: ______________________________________________________
Date: ____________________________
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Camp Oasis of Washington
Submit forms to: CCFA, Camp Oasis - 733 Third Avenue, Suite 510 – New York, NY 10017 / Email: [email protected] / Fax: (212) 779 – 4098
Camper’s Name: ____________________________________________
DOB: ________________
2016 SEVERE ALLERGY ACTION PLAN
MUST BE COMPLETED & SIGNED BY A LICENSED ALLERGIST IF YOUR CHILD REQUIRES EPINEPHRINE
IF YOUR CHILD IS NOT SEEING AN ALLERGIST THEIR PEDIATRICIAN SHOULD COMPLETE THIS FORM INSTEAD
YOU MUST SUPPLY TWO (2) EPI-PENS AT CAMP
List ANYALLERGY (to food, medicine or other) that may prompt a life-threatening allergic response.
Allergen
Severe Reaction Caused When:
Has severe reaction
ever occurred?
Required Response

Give epinephrine immediately after known exposure to
allergen, even if no symptoms are noted
Allergen touches skin

Give epinephrine at first sign of any symptom

Allergen is in area (air born allergy)


Allergen is ingested


Allergen is ingested


Yes
Date: __________
Give epinephrine with signs or symptoms of anaphylaxis

No

Give epinephrine immediately after known exposure to
allergen, even if no symptoms are noted

Allergen touches skin
Yes
Date: __________

Give epinephrine at first sign of any symptom

Allergen is in area (air born allergy)

Give epinephrine with signs or symptoms of anaphylaxis

No

Allergen is ingested

Give epinephrine immediately after known exposure to
allergen, even if no symptoms are noted


Allergen touches skin
Yes
Date: __________

Give epinephrine at first sign of any symptom

Allergen is in area (air born allergy)

Give epinephrine with signs or symptoms of anaphylaxis

No

Allergen is ingested

Give epinephrine immediately after known exposure to
allergen, even if no symptoms are noted


Allergen touches skin
Yes
Date: __________

Give epinephrine at first sign of any symptom

Allergen is in area (air born allergy)

Give epinephrine with signs or symptoms of anaphylaxis

No
Dosage & Additional
Instructions
Other Non-Life Threatening Allergies &
Recommended Treatment:
Note to Allergist: If you do not feel this form adequately addresses your patient’s allergy(ies) please feel free to submit subsequent documentation.
Allergist’s / MD’s Name:
Phone:
Allergist’s / MD’s Signature:
Date:
Camp Oasis of Washington
Submit forms to: CCFA, Camp Oasis - 733 Third Avenue, Suite 510 – New York, NY 10017 / Email: [email protected] / Fax: (212) 779 – 4098
8
Camper’s Name: ____________________________________________
DOB: ________________
2016 LEADERS IN TRAINING (LIT) PROGRAM EXPLANATION
****THIS INFORMATION IS ONLY APPLICABLE TO LIT PROGRAM APPLICANTS***
Greetings Prospective LIT (and LIT Parent/Guardian):
For our 2016 camp season, teens entering grades 11 - 12 in fall 2016 are only eligible to attend Camp Oasis as
part of our Leaders in Training (LIT) Program. Therefore, if you fall within this designation, you must apply to be
an LIT and be selected for participation in order to attend camp. Read below for more information on the program
and how to apply.
What to Expect
Our LIT Program is a special program for teens that are truly interested in developing their leadership skills.
LITs are technically still campers – which means they have plenty of time for the usual fun – but they also have
some added duties and responsibilities.
For example, LITs will be expected to:
1. Abide by all of the camp rules and set a good example for the other campers
2. Work at least one activity period a day with the help of a senior counselor
3. Help organize and run a camp-wide event during the week with the help of other LITs
4. Attend and participate in a daily LIT meeting
5. Stay the entire duration of camp
6. Assist as needed with the bunk-life of the youngest campers
Who Should Apply
We are looking for LITs who are responsible members of the camp community. We are looking for those who are
able to put the needs of others before their own, and who enthusiastically participate in camp activities. And we are
looking for good roles models - those who follow the rules and are respectful towards the other people at camp.
How to Apply
If you meet the LIT grade requirement, are willing to fulfill the duties listed above, and believe you can contribute
positively to our camp community, please complete the attached LIT Application, and send it in along with the
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other required hard copy forms by the application deadline: May 27 , 2016.
After your application is received and has been processed, someone from the Camp Office will contact you about
setting up an LIT interview. From there, a decision will be made about whether you will be able to attend.
NOTE: Not every LIT applicant is guaranteed a spot in the LIT Program. It is selective. Only those who
demonstrate that they have the required interests and skills will be accepted.
If you have any questions about the LIT Program, please contact Kathleen Newbould Waite: (425) 451 – 8455 x 6
/ [email protected].
Sincerely,
Your CCFA Camp Oasis Leadership Team
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Camper’s Name: ____________________________________________
DOB: _______________
2016 LEADER IN TRAINING (LIT) APPLICATION
***This form must be submitted along with the other required application forms by anyone applying to Camp Oasis as a Leader in Training (LIT).***
LIT Applicant’s Name: _________________________________
Gender: M / F
Grade in 2016-17: __________
Address: ______________________________ City: ______________________ State: _____ Zip: ______________
Phone(s): _____________________________________
E-mail Address: ______________________________
1.) Why do you want to be a Leader in Training at CCFA Camp Oasis? (Use other side if necessary.)
2.) What past jobs and/or experiences have prepared you for this role? (Use other side if necessary.)
Leaders in Training (LIT) Program Agreement
I recognize that by applying to serve as a Leader in Training (LIT) at CCFA’s Camp Oasis, I am seeking to join a community of caregivers
entrusted with the care and well-being of campers, and therefore agree to adhere to and uphold the following rules and policies:
Attendance: I will attend the entire session of camp and all of its activities, observe the hours of curfew, and never leave campus, unless I
make other specific arrangements with the Director beforehand.
Forbidden Items: I will not bring to camp any alcohol, illegal drugs, firearms, knives, fireworks or other explosives, pets, or any other potentially
dangerous items.
Dress Code: I will dress appropriately for work and for each activity, as outlined by the Director.
Personal Electronics: I will only use my electronic equipment in areas and times designated by the Director.
Overall Conduct: I will set a good example for all community members, abiding by all rules and showing enthusiasm for camp and its activities.
Conduct with Campers: I will treat all campers with respect, and will NOT: (1) shame them; (2) use profane or sexual language around them;
(3) touch them in spots normally covered by bathing suits; (4) touch them against their will; (5) hit or bully them; (6) use corporal punishment;
(7) allow them to participate in any activity that is potentially physically or emotionally harmful, including pranks and horseplay; (8) share the
details of my personal life with them.
Conduct with Peers and Staff: I will treat my fellow LITs and all staff with respect; and if I have a conflict or concern, I will discuss it in a timely
manner with a camp supervisor.
I confirm that I have read each of the above listed items and understand the responsibilities related to serving as an LIT at CCFA Camp Oasis.
I also understand that by signing this form, I am promising to abide by these rules and commitments, and that failure to do so may be grounds
for dismissal.
LIT Applicant’s Signature: ________________________________________ Date: ___________________________
Parent’s Signature: _____________________________________________
Date: ___________________________
10
Camp Oasis of Washington
Submit forms to: CCFA, Camp Oasis - 733 Third Avenue, Suite 510 – New York, NY 10017 / Email: [email protected] / Fax: (212) 779 – 4098
Hardcopy Forms: Submission Instructions
Upon completion of the hardcopy forms, you must submit them along with the other items requested of you
(Insurance Card/s, camper photo, etc.) to the National Office. There are currently three ways to submit your
forms/items – mail, email, and fax. Below are detailed instructions on each method as well as advice on how to
ensure delivery and expedite processing. Please Note: You are highly encouraged to submit ALL of your
hardcopy forms/items at one time. This will lead to faster processing time as less follow up will be required.
Thank you!
Mail – (most preferred method)
CCFA, Camp Oasis
Attention: Daniel Marinoni
733 Third Avenue, Suite 510
New York, NY 10017
Best Practices
 Use certified mail to track your package and confirm delivery
 Make a copy of the completed forms/items before sending them in case they get lost in the mail
 Do not bend, fold, or crease your forms/items. Use a flat 8.5” x 11” envelope
 Do not staple your forms/items together. Use a paperclip or leave them loose in the envelope
 Do not send blank or unused forms. Only submit applicable forms that have been completed
Email
[email protected]
Best Practices
 Request a “Read Receipt” to confirm the email has been received and opened
 Include your child’s first and last name, and the camp they are applying to in the subject line
 The preferred format for all files is PDF. Other formats such as JPEG will also be accepted
 Use higher resolutions for images so they are clear and easy to read and see
 Do not send emails over 6MBs. Instead send multiple emails with fewer attachments
Fax – (least preferred method)
(212) 779 – 4098
Best Practices
 Request a “Confirmation Report” to confirm the fax went through
 Send to the attention of “Camp Oasis – Daniel Marinoni”
 Always use the highest resolution setting possible
 Do not send images or photos. Insurance cards and photos will not come through. Use email instead
Thank you again for your cooperation! Depending on the volume of hardcopy forms/items received, processing
times could take as long as two weeks. You can check if your forms/items have been processed at anytime by
logging into your account: online.ccfa.org/CampOasisLogin, clicking “View/Edit Forms,” and then clicking
“View” next to the 2016 For Campers Only – Forms Receipt Record. If you have any questions please contact
National Camp Manager, Daniel Marinoni, at (646) 943 – 7480 or [email protected].
Application Process FAQ
Q:
Where are the hardcopy forms?
The hardcopy forms can be found via the link in Step 2 of the email entitled, “2016 CCFA Camp Oasis:
Hardcopy Forms to Complete Application.” If the link is not clickable, copy and paste it into your browser. If
pasting the link into your browser does not work please contact CCFA’s National Office.
Q:
Where do I submit the hardcopy forms once they are complete?
Please submit the hardcopy forms, as well as the attendance fee, to CCFA’s National Office.
Mail: CCFA, Camp Oasis – Attn: Daniel Marinoni – 733 Third Ave., Suite 510 – New York, NY 10017
Email: [email protected]
Fax: (212) 779 – 4098
Q:
How can I find out if the National Office received my hardcopy forms?
You can check if your forms have been received and processed at anytime by logging into your account:
online.ccfa.org/CampOasisLogin, clicking “View/Edit Forms,” and then clicking “View” next to the 2016 For
Campers Only – Forms Receipt Record. If there is a date written next to the form then it has been received
and processed. If there is no date then the form is either missing or it has not been processed yet.
Note: Depending on the volume of forms received processing times may take as long as two weeks.
Q:
My child’s medication has changed. How can I update their medication list?
You can update your child’s Current Medication List at anytime by visiting:
online.ccfa.org/CampOasisMedUpdate. Please do NOT submit another application.
Note: If you update your child’s medication, you will be required to submit another Current Medication List
signed by your child’s GI/NP. If you think your child’s medication might change a second or third time, it’s
best to wait and indicate those changes on the “Pre-Camp Update Form” which is sent two weeks prior to
your camp’s start date.
Q:
My child’s medical history has changed. How can I update their application?
Two weeks prior to camp you will receive Pre-Camp Update Form where you can update your child’s
application with any recent changes to their medical history. Please do NOT submit another application.
However, if your child’s condition has changed significantly (i.e., surgery is now required), please contact
your local camp office to share this update as soon as possible.
Q:
My child’s application is complete. Now what?
A medical review team will review the application and determine whether CCFA can accommodate the child
during camp. After being reviewed, the medical team will inform the local CCFA Regional Education &
Support Manager (RESM) that the child should accepted or rejected. The RESM will then communicate that
decision to you. If accepted, the RESM will become the primary point of contact leading up to camp.
Q:
My child can no longer attend camp. Who should I contact?
Please contact National Camp Manager, Daniel Marinoni, or your local RESM as soon as possible so that
another child can take their place as many of our camps run a wait list.
Q:
I have a question. Who should I contact?
If you have a question regarding the application process including the online application, hardcopy forms,
attendance fee, or scholarship request – please contact, National Camp Manager, Daniel Marinoni: (646)
943 – 7480 / [email protected]
If you have questions regarding your child’s acceptance, the camp host site, or the camp session itself
including accommodations, activities, menu, etc. – please contact your local RESM. If you do not know who
your local RESM is please visit: www.ccfa.org/chapters
2015 Recommended Immunizations for Children from 7 Through 18 Years Old
7–10 YEARS
11-12 YEARS
13-18 YEARS
Tdap 1
Tetanus, Diphtheria, Pertussis (Tdap) Vaccine
Tdap
Human Papillomavirus (HPV) Vaccine (3 Doses)2
HPV
MCV4
Meningococcal Conjugate Vaccine (MCV4) Dose 13
MCV4 Dose 13
Booster at age 16 years
Influenza (Yearly)4
Pneumococcal Vaccine5
Hepatitis A (HepA) Vaccine Series6
Hepatitis B (HepB) Vaccine Series
Inactivated Polio Vaccine (IPV) Series
Measles, Mumps, Rubella (MMR) Vaccine Series
Varicella Vaccine Series
These shaded boxes indicate when the vaccine is
recommended for all children unless your doctor tells
you that your child cannot safely receive the vaccine.
These shaded boxes indicate the
vaccine should be given if a child is
catching-up on missed vaccines.
These shaded boxes indicate the vaccine is recommended for children with certain health
conditions that put them at high risk for serious diseases. Note that healthy children can get the
HepA series6. See vaccine-specific recommendations at www.cdc.gov/vaccines/pubs/ACIP-list.htm.
FOOTNOTES
Tdap vaccine is recommended at age 11 or 12 to protect against tetanus, diphtheria and pertussis. If your child has not received any or all of the DTaP
vaccine series, or if you don’t know if your child has received these shots, your child needs a single dose of Tdap when they are 7 -10 years old. Talk to
your child’s health care provider to find out if they need additional catch-up vaccines.
2
All 11 or 12 year olds – both girls and boys – should receive 3 doses of HPV vaccine to protect against HPV-related disease. The full HPV vaccine series
should be given as recommended for best protection.
3
Meningococcal conjugate vaccine (MCV) is recommended at age 11 or 12. A booster shot is recommended at age 16. Teens who received MCV for the
first time at age 13 through 15 years will need a one-time booster dose between the ages of 16 and 18 years. If your teenager missed getting the vaccine
altogether, ask their health care provider about getting it now, especially if your teenager is about to move into a college dorm or military barracks.
4
Everyone 6 months of age and older—including preteens and teens—should get a flu vaccine every year. Children under the age of 9 years may require
more than one dose. Talk to your child’s health care provider to find out if they need more than one dose.
5
Pneumococcal Conjugate Vaccine (PCV13) and Pneumococcal Polysaccharide Vaccine (PPSV23) are recommended for some children 6 through 18 years old with
certain medical conditions that place them at high risk. Talk to your healthcare provider about pneumococcal vaccines and what factors may place your child at
high risk for pneumococcal disease.
6
Hepatitis A vaccination is recommended for older children with certain medical conditions that place them at high risk. HepA vaccine is licensed, safe,
and effective for all children of all ages. Even if your child is not at high risk, you may decide you want your child protected against HepA. Talk to your
healthcare provider about HepA vaccine and what factors may place your child at high risk for HepA.
1
For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit http://www.cdc.gov/vaccines/teens
Vaccine-Preventable Diseases and the Vaccines that Prevent Them
Diphtheria (Can be prevented by Tdap vaccine)
Diphtheria is a very contagious bacterial disease that affects the
respiratory system, including the lungs. Diphtheria bacteria can be
passed from person to person by direct contact with droplets from
an infected person’s cough or sneeze. When people are infected,
the diptheria bacteria produce a toxin (poison) in the body that
can cause weakness, sore throat, low-grade fever, and swollen
glands in the neck. Effects from this toxin can also lead to swelling of the heart muscle and, in some cases, heart failure. In severe
cases, the illness can cause coma, paralysis, and even death.
Hepatitis A (Can be prevented by HepA vaccine)
Hepatitis A is an infection in the liver caused by hepatitis A virus. The
virus is spread primarily person-to-person through the fecal-oral
route. In other words, the virus is taken in by mouth from contact
with objects, food, or drinks contaminated by the feces (stool) of an
infected person. Symptoms include fever, tiredness, loss of appetite,
nausea, abdominal discomfort, dark urine, and jaundice (yellowing
of the skin and eyes). An infected person may have no symptoms,
may have mild illness for a week or two, or may have severe illness
for several months that requires hospitalization. In the U.S., about
100 people a year die from hepatitis A.
Hepatitis B (Can be prevented by HepB vaccine)
Hepatitis B is an infection of the liver caused by hepatits B virus.
The virus spreads through exchange of blood or other body fluids,
for example, from sharing personal items, such as razors or during
sex. Hepatitis B causes a flu-like illness with loss of appetite, nausea,
vomiting, rashes, joint pain, and jaundice. The virus stays in the liver
of some people for the rest of their lives and can result in severe liver
diseases, including fatal cancer.
Human Papillomavirus (Can be prevented by HPV vaccine)
Human papillomavirus is a common virus. HPV is most common
in people in their teens and early 20s. It is the major cause of
cervical cancer in women and genital warts in women and men.
The strains of HPV that cause cervical cancer and genital warts
are spread during sex.
Influenza (Can be prevented by annual flu vaccine)
Influenza is a highly contagious viral infection of the nose, throat, and
lungs. The virus spreads easily through droplets when an infected
person coughs or sneezes and can cause mild to severe illness. Typical
symptoms include a sudden high fever, chills, a dry cough, headache,
runny nose, sore throat, and muscle and joint pain. Extreme fatigue
can last from several days to weeks. Influenza may lead to hospitalization
or even death, even among previously healthy children.
Measles (Can be prevented by MMR vaccine)
Measles is one of the most contagious viral diseases. Measles
virus is spread by direct contact with the airborne respiratory
droplets of an infected person. Measles is so contagious that just
being in the same room after a person who has measles has already
left can result in infection. Symptoms usually include a rash, fever,
cough, and red, watery eyes. Fever can persist, rash can last for up
to a week, and coughing can last about 10 days. Measles can also
cause pneumonia, seizures, brain damage, or death.
Meningococcal Disease (Can be prevented by MCV vaccine)
Meningococcal disease is caused by bacteria and is a leading
cause of bacterial meningitis (infection around the brain and
spinal cord) in children. The bacteria are spread through the
exchange of nose and throat droplets, such as when coughing,
sneezing or kissing. Symptoms include nausea, vomiting,
sensitivity to light, confusion and sleepiness. Meningococcal
disease also causes blood infections. About one of every
ten people who get the disease dies from it. Survivors of
meningococcal disease may lose their arms or legs, become
deaf, have problems with their nervous systems, become developmentally disabled, or suffer seizures or strokes.
Mumps (Can be prevented by MMR vaccine)
Mumps is an infectious disease caused by the mumps virus,
which is spread in the air by a cough or sneeze from an infected
person. A child can also get infected with mumps by coming
in contact with a contaminated object, like a toy. The mumps
virus causes fever, headaches, painful swelling of the salivary
glands under the jaw, fever, muscle aches, tiredness, and loss of
appetite. Severe complications for children who get mumps are
uncommon, but can include meningitis (infection of the covering of the brain and spinal cord), encephalitis (inflammation of
the brain), permanent hearing loss, or swelling of the testes,
which rarely can lead to sterility in men.
Pertussis (Whooping Cough) (Can be prevented by Tdap vaccine)
Pertussis is caused by bacteria spread through direct contact
with respiratory droplets when an infected person coughs or
sneezes. In the beginning, symptoms of pertussis are similar to
the common cold, including runny nose, sneezing, and cough.
After 1-2 weeks, pertussis can cause spells of violent coughing
and choking, making it hard to breathe, drink, or eat. This cough
can last for weeks. Pertussis is most serious for babies, who can
get pneumonia, have seizures, become brain damaged, or even
die. About two-thirds of children under 1 year of age who get
pertussis must be hospitalized.
Pneumococcal Disease
(Can be prevented by Pneumococcal vaccine)
Pneumonia is an infection of the lungs that can be caused by the
bacteria called pneumococcus. This bacteria can cause other
types of infections too, such as ear infections, sinus infections,
meningitis (infection of the covering around the brain and spinal
If you have any questions about your child’s vaccines, talk to your healthcare provider.
cord), bacteremia and sepsis (blood stream infection). Sinus and
ear infections are usually mild and are much more common than
the more severe forms of pneumococcal disease. However, in
some cases pneumococcal disease can be fatal or result in longterm problems, like brain damage, hearing loss and limb loss.
Pneumococcal disease spreads when people cough or sneeze.
Many people have the bacteria in their nose or throat at one time
or another without being ill—this is known as being a carrier.
Polio (Can be prevented by IPV vaccine)
Polio is caused by a virus that lives in an infected person’s throat
and intestines. It spreads through contact with the feces (stool)
of an infected person and through droplets from a sneeze or
cough. Symptoms typically include sudden fever, sore throat,
headache, muscle weakness, and pain. In about 1% of cases,
polio can cause paralysis. Among those who are paralyzed, up to
5% of children may die because they become unable to breathe.
Rubella (German Measles)
(Can be prevented by MMR vaccine)
Rubella is caused by a virus that is spread through coughing and
sneezing. In children rubella usually causes a mild illness with
fever, swollen glands, and a rash that lasts about 3 days. Rubella
rarely causes serious illness or complications in children, but can
be very serious to a baby in the womb. If a pregnant woman is
infected, the result to the baby can be devastating, including
miscarriage, serious heart defects, mental retardation and loss of
hearing and eye sight.
Tetanus (Lockjaw)
(Can be prevented by Tdap vaccine)
Tetanus is caused by bacteria found in soil. The bacteria enters
the body through a wound, such as a deep cut. When people are
infected, the bacteria produce a toxin (poison) in the body that
causes serious, painful spasms and stiffness of all muscles in the
body. This can lead to “locking” of the jaw so a person cannot
open his or her mouth, swallow, or breathe. Complete recovery
from tetanus can take months. Three of ten people who get
tetanus die from the disease.
Varicella (Chickenpox)
(Can be prevented by varicella vaccine)
Chickenpox is caused by the varicella zoster virus. Chickenpox
is very contagious and spreads very easily from infected people.
The virus can spread from either a cough, sneeze. It can also
spread from the blisters on the skin, either by touching them or
by breathing in these viral particles. Typical symptoms of chickenpox include an itchy rash with blisters, tiredness, headache
and fever. Chickenpox is usually mild, but it can lead to severe
skin infections, pneumonia, encephalitis (brain swelling), or even
death.
Last updated on 02/02/2015 • CS254242-A