Summer Camp - Rocky Mountain Farmers Union

Step 1 of 9

Parent/Guardian 1: Information
Parent 1: Name(Required)
First Last
Parent 1: Cell Phone(Required)
Parent 1: Email(Required)
Enter Email Confirm Email

Parent 1: Address(Required)
Street Address City State ZIP Code

Parent 1: Employer Information(Required)
Employer's Name Address City State ZIP Code

Parent 1: Employer Phone(Required)
This number will only be used if we cannot get a hold of either parent or emergency contact.

Parent/Guardian 2: Information
If there is not a second parent to be listed, please mark fields with N/A.
Parent 2: Name(Required)
First Last
Parent 2: Cell Phone
Parent 2: Email
Enter Email Confirm Email

Parent 2: Address
Street Address City State ZIP Code

Parent 2: Employer Information
Employer Name Street Address City State ZIP Code

Parent 2: Employer Phone
This number will only be used if we cannot get in contact with either parent or listed emergency contact.

Emergency Contact: Information
Emergency contact, if not available in an emergency, notify:
Emergency Contact: Name(Required)
First Last
Emergency Contact: Phone(Required)
Emergency Contact: Email(Required)
Enter Email Confirm Email

Emergency Contact: Address(Required)
Street Address City State ZIP Code

Transportation
Parents are responsible for transportation to and from camp. Please list a secondary pick-up/drop-off person that is someone other than a parent.
Secondary pick up/drop off person(Required)
This camper will NOT be allowed to leave with anyone not listed. A camp staff member may request identification.
First Last
Relationship(Required)

Cell Phone(Required)
Address(Required)
Street Address City State ZIP Code

Is there a person the camper is NOT allowed to leave with?(Required)
Name(Required)

Parental/Guardian Permission
All signature fields must have a parent's signature.
Permission(Required)

I hereby give permission for my child to go on trips away from camp premises, whether on foot or by vehicle.

I do NOT give permission for my child to go on trips away from camp premises, whether on foot or by vehicle.
Parent Signature(Required)
First Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Permission(Required)
I hereby give permission for my child to participate in all camp activities, except for the following restrictions, explain below.
List Restrictions

Parent Signature(Required)
First Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Permissions(Required)

I hereby give permission for my child's photo to be taken and used for camp promotional and/or educational purposes.

I do NOT give permission for my child's photo to be taken and used for camp promotional and/or educational purposes. Choice
Parent Signature(Required)
First Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Permission(Required)

I allow for my child's contact information to be shared with other campers.

I do NOT allow for my child's contact information to be shared with other campers.
Parent Signature(Required)
First Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Administration of over-the-counter (OTC) medications and drugs.(Required)
Over-the-counter (OTC) medications are drugs that do not require a prescription and are purchased “over-the-counter.” This consent is required before OTC medications can be administered at camp. All OTC medications are under the care and supervision of our camp nurse.
List Exception

Parent Signature(Required)
First Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Application of Sunscreen
Our Camp experience includes spending a considerable amount of time outdoors and we want to take the precautionary steps to limit exposure by using sunscreen during outdoor activities. Sunscreen is applied under the supervision of the camp nurse and can be delegated to camp staff to apply. An SPF-30 or higher sunscreen will be applied to campers when outside during the day. Sunscreen will be applied to exposed skin and will be reapplied, as needed. Please mark all applicable information regarding the type and use of sunscreen for your child:
Parent Permission to Apply Sunscreen(Required)
I do not know of any allergies my child has to sunscreen.
Staff may use the sunscreen of their choice following the directions printed on the bottle.
I have provided the following brand/type of sunscreen for use on my child. Please list name of sunscreen:
Name of Sunscreen to be used on your child and/or any special instructions we may need to be aware of.

Please provide appropriate sunscreen if your child has specific allergies to sunscreen.
Parent Signature(Required)
First Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Consent(Required)
Acknowledgement of Responsibility and Release of Liability
Our child will attend the Rocky Mountain Farmers Union Cooperative Leadership Camp in June 2022. In consideration of his or her attendance at the Camp, we agree that Rocky Mountain Farmers Union and La Foret Conference Center are not responsible for any accident or injury affecting my child or children during the time spent at camp or while being transported to or from the camp or camp activities. We agree to hold harmless and indemnify Rocky Mountain Farmers Union, La Foret Conference Center, and their staffs, representatives, and employees from all liability in relation to our use of the premises, travel to and from the camp, engagement in Camp activities, use of materials or equipment, buildings and/or operations of the Rocky Mountain Farmers Union Cooperative Leadership Camp. We hereby agree to release the above entities from all liability for any economic and non-economic losses due to bodily injury, death, and/or property damage sustained by me and/or my minor child or legal ward. We understand that Rocky Mountain Farmers Union and La Foret Conference Center will take all reasonable precautions to ensure the safety, health and well-being of my child by the exercise of due care and by following all regulations and guidelines.

Parent Signature(Required)
First Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Date(Required)
MM slash DD slash YYYY

Is the child covered by family health insurance?
Yes
No
Upload a copy of the FRONT of camper's health insurance card
Max. file size: 50 MB.
Health Insurance: please upload a copy of the FRONT of the camper's health insurance card.
Upload a copy of the BACK of camper's health insurance card
Max. file size: 50 MB.
Health Insurance: please upload a copy of the BACK of the camper's health insurance card.
Upload official Colorado Department of Health & Environment Certificate of Immunization
Max. file size: 50 MB.
Immunization: Please upload a copy of the child’s official Certification of Immunizations issued by the Colorado Department of Public Health and Environment (CDPHE) record including the date of the last tetanus shot.
What was the date of your last physical examination?
MM slash DD slash YYYY

Upload physical examination form
Max. file size: 50 MB.
Physical Examination: must be signed by your doctor and performed within the preceding 24 months of the camp dates.

General Health History
To be completed by a parent or legal guardian. Check “Yes” or “No” for each statement. Explain “Yes” answers below. Has/Does This Camper:
1. Ever been hospitalized?(Required)

Yes

No
2. Ever had surgery?(Required)

Yes

No
3. Have recurrent chronic illnesses?(Required)

Yes

No
4. Had a recent infectious disease?(Required)

Yes

No
5. Had a recent injury?(Required)

Yes

No
6. Have asthma, wheezing, shortness of breath?(Required)

Yes

No
7. Have diabetes?(Required)

Yes

No
8. Had seizures?(Required)

Yes

No
9. Had headaches?(Required)

Yes

No
10. Wears glasses, contacts, protective eye wear?(Required)

Yes

No
11. Had fainting or dizziness?(Required)

Yes

No
12. Passed out or had chest pain during exercise?(Required)

Yes

No
13. Had a (mono)nucleosis during the past 12 months?(Required)

Yes

No
14. If female, have problems with menstruation?(Required)

Yes

No
15. Have problems with falling asleep or sleepwalking?(Required)

Yes

No
16. Ever had back or joint problems?(Required)

Yes

No
17. Have a history of bed wetting?(Required)

Yes

No
18. Have problems with diarrhea or constipation?(Required)

Yes

No
19. Have any skin problems?(Required)

Yes

No
20. Current medications?(Required)

Yes

No
21. Special diet?(Required)

Yes

No
22. Any known drug reactions?(Required)

Yes

No
23. Allergies?(Required)

Yes

No
24. Traveled outside of the country in the past 9 months?(Required)

Yes

No
Where, country and dates(Required)

25. Ever been treated for attention deficit disorder (ADD) or Attention Deficit Hyperactivity Disorder (AD/HD)?(Required)

Yes

No
26. Ever been treated for emotional or behavioral difficulties or an eating disorder?(Required)

Yes

No
27. During the past 12 months, seen a professional to address mental/emotional health concerns?(Required)

Yes

No
28. Had a significant life event that continues to affect the camper’s life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)(Required)

Yes

No
Please explain “Yes” answers in the space below, noting the number of the question.
What have we forgotten to ask?

Please provide any additional information about the camper's health that you think is important or that may affect the camper's ability to fully participate in the camp program. Attach additional information if needed.

Parent Signature
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 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. If for a religious, medical, or personal reason you do not desire to sign this, contact the camp for a legal waiver which must be signed for attendance.
Signature
First Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Payment
Total

Billing Address
Street Address City State ZIP Code

This address must match the address on the credit card being used.
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date Month Year
Security Code Cardholder Name
Phone
This field is for validation purposes and should be left unchanged.

RMFU Summer Camp

June 8-11, at the La Foret Conference Center in the Black Forest

Camper Registration: Required Documentation

2022 Camps

Cost

About the Camper

Parent/Guardian 1: Information

Parent/Guardian 2: Information

Emergency Contact: Information

Transportation

Parental/Guardian Permission

Application of Sunscreen

General Health History

Payment