galactic trek - Scouting Event

Transcripción

2013 Cub Scout &
Webelos Resident Camp
“GALACTIC TREK”
Little Sioux Scout Ranch; Little Sioux, IA
10 sessions starting June 16-18 through July 25-27, 2013
This guide provides you with the information needed for
your Scouts’ visit to Cub Scout & Webelos Resident Camp at LSSR.
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Table of contents
 Vision, Introduction, and about Resident Camp ……………………………………….....
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 Before Camp
o Session dates and fee structure ………………………………………………………… 4
o Camperships & Refunds …………………………………………………………………. 4
o Scout to adult ratios ………………………………………………………………………. 5
o Other pre-camp information ……………………………………………………………… 6
 Special needs ……………………………………………………………………. 6
 Tour permits ……………………………………………………………………… 6
 Insurance ………………………………………………………………………… 6
 Health forms …………………………………………………………………… 6-7
o Camp orientation & Open House ……………………………………………………..... 7
o What to bring ………………………………………………………………………………. 7
o Directions to camp …………………………………………………………………………8
 At Camp
o Arrival and check-in procedures ………………………………………………………… 9
o Sleeping arrangements …………………………………………………………………... 9
o Showers…………………………………………………………………………………….. 9
o Valuables & gear ………………………………………………………………………….. 10
o Emergencies ………………………………………………………………………………. 10
 Program Information
o Daily schedule/A typical day at camp ………………………………………………….. 11
o Program offerings …………………………………………………………………………. 12-13
o Map of camp ………………………………………………………………………………. 14
 Departure from camp
o Evaluations ………………………………………………………………………………… 15
o Campsite clean-up and check-out ………………………………………………………. 15
 Other
o Camp policies & rules ……………………………………………………………………. 16-18
o Contact information ……………………………………………………………………….. 18
o Forms (health forms, camperships, refund request, special needs) ……………... 19-26
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MID-AMERICA COUNCIL MISSION STATEMENT
It is the mission of the Mid-America Council to provide unparalleled experiences for more youth.
INTRODUCTION
Welcome to the Mid-America Council 2013 Cub Scout & Webelos Resident Camp Scout and Adult
Leaders’ Guide. In this guide, you will find the information needed to prepare for a great camping
experience with your Scouts. You will find arrival and departure times, locations, daily schedules, a listing of
activities planned throughout the week and an overview of what to expect from your days at camp.
Resident camp program
We are so excited to be holding Resident Camp at Little Sioux Scout Ranch for Tigers, Wolves, Bears and
Webelos! Our Cub Scout program is for Tigers, Wolves and Bears (After June 1, this is any brand new
Tiger Cubs, any Tigers moving into the Wolf program, and Wolves moving into the Bear program). To
ensure each Cub Scout has a well-rounded camp experience, our 8:30 a.m. – 12:00 p.m. and 1:30 p.m. –
5:00 p.m. program rotations will be done in a round robin with Scouts having a chance to visit each
program area.
Our Webelos program is for both Webelos 1 & 2 (After June 1, this is any Bears moving into Webelos 1,
and Webelos 1’s moving into Webelos 2). Webelos will get to experience an exciting “Trek” program, and
can self-select other activities that interest them.
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SESSIONS AND fees
2013 Resident Camp Dates
Each session is limited to the first 150 Scouts to register.
Session 1
June 16-18, 2013
Session 2
June 20-22, 2013
Session 3
June 23-25, 2013
Session 4
June 27-29, 2013
Session 5
July 7-9, 2013
Session 6
June 11-13, 2013
Session 7
July 14-16, 2013
Session 8
July 18-20, 2013
Session 9
July 21-23, 2013
Session 10
July 25-27, 2013
Resident camp fees
2013 Camp Fees for Scouts
 If registered by May 31 = $110.00.
 If registered after May 31 = $120.00
2013 Camp Fees for Adults & Leaders
 If registered by May 31 = $75.00
 If registered after May 31 = $85.00
Scouts whose full fees are paid by May 31 will receive a free camp patch. To meet camp fee deadlines,
fees must be fully paid through the online registration system, or at the Durham Scout Center or Sioux City
Service Center.
CAMPERSHIPS
We do not want any Scout to miss out on the opportunity to attend resident camp due to financial need. We
have some funds to help Scouts who need financial assistance attend camp. Scouts from units that conduct
an FOS campaign and participate in popcorn sales will receive first priority. All campership information is
kept confidential. Campership applications must be received in the Durham Scout Center at least one
month prior to the start of your session date.
refunds
Part of a Scout or Leader’s fee will be refunded only under one of the following circumstances:
 Individual illness or injury
 Death or serious illness in the immediate family
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 Relocation of the family outside of Mid-America Council.
The Cubmaster must make such requests in writing. No refunds may be requested after a Pack leaves
camp. Any refund due to a Pack will be credited to the Pack’s pre-paid account at the Durham Scout
Center. Pre-registration fees for a Scout or Scouter may be transferred to another Scout or Scouter.
Cub scout to adult attendance ratio
Wolf & Bear Scouts
# of Scouts
# of Adults
1-8
2
BSA National Standard of Two
Deep Leadership
requires these ratios
Webelos Ratios
# of Scouts
# of Adults
2
1-10
BSA National Standard of Two Deep Leadership
Any adults must be at least 21 years of age and a registered leader or participating parent. National
Scouting policy requires two-deep leadership (two registered adult leaders/parents). It is not required that
each Scout have their parent/guardian attend for the Scout to attend. Our Resident Camp maintains the
above ratios of leadership to ensure BSA’s National Standard is met. All adults must show proof of current
Youth Protection training to attend. To get trained, visit www.MyScouting.org. You will need to create a free
account and click on “E-Learning” then “Youth Protection Training.” You can print the certificate of
completion and bring with you to camp.
In the instance that a Pack does not have a second or subsequent leader/parent, we will pair those Scouts
and leaders with another pack to allow them to attend. However, there must be at least one leader in camp
at all times from each unit for every rank for which they have Scouts attending. Webelos I and Webelos II
are considered separate ranks as they will camp separately and have separate programs.
All units must have at least at least two adults to a maximum of eight Scouts, and one additional adult for
each four boys (or part thereof) for both Cub Scouts and Webelos.
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OTHER PRE-CAMP INFORMATION
Special needs
We are working hard to make our camp comfortable and accessible to those with special needs.
If anyone in your unit has special dietary, health, or mobility needs we ask that you please make your needs
known as soon as possible to allow time for reasonable accommodations for your requests. Be specific and
indicate a contact person in case your camp director has any questions in meeting the accommodation.
Deadline for special requests is two weeks before the start of your camp session – please use the form
found in this packet or download it from our website under the ‘Camping’ pages, then ‘Resources.’
Peanut Allergy: We recognize that the occasional Scout or Scouter may have a peanut allergy. We are not
able to create a peanut free environment camp. However, peanut free tables will be identified in the dining
pavilion if needed.
Tour permits
Mid-America Council Packs attending LSSR Resident Camp do not need to file a tour permit. Any out-ofcouncil Packs visiting our camp will need to file one in accordance with their Council’s policies.
Insurance
All adult leaders and campers must be registered members of the Boy Scouts of America. The MidAmerica Council has purchased the National Boy Scouts of America Council Accident & Sickness Insurance
Plan, which will cover all registered Mid-America Council Pack, Troop, and/or Crew members for both
accidents and illnesses that manifest during participation in Scouting activities. All out-of-council units and
other groups or individuals attending camp will not be covered by the Mid-America Council plan. In those
instances, accident and health insurance is the responsibility of the Pack, individual, and parents or
guardians.
Health Forms
All medical forms must be new 2013 parts A & B. School physical forms cannot be accepted. Physician
and parent/guardian signatures must be original and within the past 12 months. Please use the appropriate
form and bring it to camp. There are no waivers or exceptions.
Our health lodge is maintained and staffed with qualified personnel for the health and safety of all campers
at all times. The health officer must check all medications, prescription and non-prescription drugs brought
to camp. All medications must be brought in the original container, along with a written authorization from
the parent or guardian to administer them. All injuries occurring at camp must be reported to the health
lodge and registered in the camp first-aid log.
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Camp orientation meeting & open house
This meeting is designed to inform Pack and Den leaders and parents what they should be doing to prepare
their boys for resident camp. Some of the information will include: program highlights, camp fees, important
dates, and what Scouts should do before they come to camp. There will also be time for leaders to ask
questions. This meeting is NOT mandatory and is intended to help those leaders, especially new leaders,
who want their Scouts to get everything they can out of the Cub and Webelos Resident Camp experience.
Date
May 11, 2013
Time
9:30–11:00 am
Location
Little Sioux Scout Ranch
This orientation meeting will be held during our Little Sioux Scout Ranch Open House. Our open house is
a great way for parents, leaders and Scouts to check out Little Sioux before camp. There will be training
opportunities for adults, program areas open for Scouts to participate in, and FREE overnight camping on
Friday, May 10. For more information or to sign up, visit www.mac-bsa.org.
WHAT TO BRING TO RESIDENT CAMP
 Health Form (completed and current).
 Official Scout uniform (shorts, Pack
neckerchief w/slide, shorts, belt and
socks).
 Camp t-shirt (will receive upon check-in
at camp if fully paid by May 31).
 Extra shirts, shorts, underwear, socks,
etc.
 Pajamas
 Sweater or light jacket
 Jeans or long pants
 Swimming suit (see additional notes
below).
 Sunblock
 Raincoat or poncho
 Hiking boots or sturdy tennis shoes
 Hat or cap
 Bath towels
 Toothbrush & toothpaste
 Shampoo, soap, comb
 Sleeping bag or blankets, pillow
 Water shoes or 2nd pair for rowboating
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Personal tent
Flashlight & extra batteries
Scout rank handbook
Paper & writing utensil
Mosquito repellent (non-aerosol)
Water bottle or hydration pack
Excitement for camp!
Optional Items:
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Envelopes & stamps
Camera
Sunglasses
Musical instrument
Sewing kit
Trash bags
Football/frisbee/etc.
Deck of cards
Money for camp trading post (please do
not bring an excess of cash).
SWIMSUITS
Men – trunk style suits only. No competition style swimsuits such as Speedos or Jammers.
Women – One piece swimming suits only. Must be conservatively cut in legs, back and chest.
SCOUT UNFORM
Scouts and leaders should wear Scout uniforms at all evening flag ceremonies and evening meals.
Directions to little Sioux scout ranch
Physical address is: 32977 Larpenteur Memorial Road Little Sioux, Iowa 51545.*
From Omaha: I-29 North to exit 95 toward Little Sioux. Turn right onto Vine Street Drive 1.7 miles and turn
left onto Main Street/CR-F20. There is a LSSR sign on the southwest corner. Drive 2.2 miles on CR-F20
until you come to the fork in the road. Take the left fork and drive 3.4 miles on Larpenteur Memorial Road
until you reach the camp on the right side of the road.
From Sioux City: Take I-29 South to exit 105 toward Blencoe. Turn left onto Highway East 60. Drive 8.7
miles following Highway E-60. Turn right onto Larpenteur Memorial Road. Drive 1.6 miles south until you
reach the camp gate on the left side of the road.
*Using MapQuest or GPS devices for directions will take you in the wrong direction. We recommend using
the written directions above.
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At camp
reminders
 Check-in for your session will occur between 2 and 4 p.m.
 Please do NOT arrive before 1:45 p.m. Early arrivals are not able to be accommodated.
 One car per Pack will be allowed to drop off equipment at campsites.
 Carts & wheelbarrows are available for moving gear.
ARRIVAL TO CAMP
Please plan to arrive between 2:00 p.m. and 4:00 p.m. on the first day of your session.
Upon arriving, please have one adult leader from each unit collect and turn in all medical forms. If you have
a single Scout with you, that adult should turn in their form. There will be an orientation meeting at 4:30
p.m. for all parents and leaders.
The leader who checks in the Den or Pack will be issued wristbands for the identification of all who are
staying at camp. For security, the wristbands are required to be worn at all times to help verify individuals
who are authorized to be on camp grounds. Individuals without wristbands will be asked to go to the camp
office.
During check-in, the leader will be issued one vehicle pass, which, weather permitting, can be used to
transport personal gear to the trail head of the Pack’s campsite. Each Pack will be permitted to bring only
one vehicle at a time to the trail head. This vehicle must be attended at all times and returned to the longterm parking area immediately after unloading. Except for loading and unloading, only camp service
vehicles are allowed beyond the parking area. Camp staff will be available to assist with this process.
Sleeping Arrangements
Once in your campsite, Scouts and leaders will be assigned areas to set up their tents. Each camper will
need to bring their own tent and sleeping items to be comfortable (sleeping bag, blankets, pillows,
pads, etc).
Showers
Showers are open to youth between 7:00 a.m. and 10:00 p.m., and open to adults between 10:00 p.m. and
7:00 a.m. Please follow this policy in order to help us maintain youth protection standards.
Valuables and Gear
Leaders should ask Scouts to bring as few valuables as possible to camp. Each unit is advised if possible to
have a leader responsible for their Scout’s money to prevent lost/stolen money. Adult supervision is a
MUST. Scouts are not permitted to walk through other units’ campsites. Scouts should be encouraged to
respect their own gear as well as that of all others. LSSR and the Mid-America Council work hard and spend
a great deal of money to provide tools, program supplies, etc. for the enjoyment of all our visitors. Please
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oversee the behavior of your Scouts to guard against theft or vandalism of camp property. If we take care of
all we have, things at LSSR will only get better!
All Scouts and adults must bring a plastic or metal cup, canteen, refillable water bottle, or hydration pack
which must be carried at all times in order to help prevent dehydration. A rain poncho and flashlight are also
highly recommended. Scouts may also choose to bring a day pack or other bag in which to carry these
items and other incidentals. These items may also be purchased at the trading post.
Scouts are permitted to bring snacks to camp. However, storing food in tents can attract animals, so
campers do so at their own risk. If you bring snacks, you are advised to bring individually packaged, healthy
items such as granola bars. Meals provided supply sufficient nutrition and energy for the week and the
trading post will be open for additional snacks.
Emergencies
During the business hours of 8:30 a.m. to 4:30 p.m. Monday through Friday, call the Camp Ranger at (402)
910-0854, the Camp Director at (402) 731-1324 or the Durham Scout Center at (402) 431-9272. If you are
calling the Council office state the nature of the emergency and provide a contact name, unit number and
phone number, and we will contact the camp as soon as possible. Also understand that you may normally
reach a voicemail, but we will work diligently to respond as quickly as voicemails can be retrieved.
The “s’ rules
 Stay with a buddy.
 Stay within camp boundaries.
 Sanitation – scrub with soap!
 Stay out of other people’s stuff. Permission must be given to enter another’s sleeping area.
 Sticks & stones stay on the ground.
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Camp schedule/a typical day in camp
Morning routine
Each morning, all campers will assemble at the flagpoles at the parade grounds at 7:15 a.m. for the flag
raising, which will be followed by breakfast in the dining pavilion.
Meals
Meals are served cafeteria-style and will be followed by a brief period of announcements and other
merriment. Dens need to remain at their tables until dismissed.
MORNING & AFTERNOON PROGRAMS
Throughout your time at camp, dens will travel with their adult leaders and staff to various program stations
and activities. Adult leaders may be asked to assist the staff as needed. Dens will be provided activity
schedules, and it is essential these are followed in order for camp to run smoothly.
EVENING ACTIVITIES
Each evening, a different (optional) fun activity will be announced.
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2013 Tiger,Wolf, Bear, Webelos Camp General Schedule
Day 1
2:00 PM – 4:00 PM
2:00 PM – 4:30 PM
4:30 PM
4:30 PM
5:45 PM
6:00 PM – 6:45 PM
6:45 PM – 7:15 PM
7:15 PM – 8:45 PM
9:00 PM – 9:45 PM
10:00 PM
Registration
Campsite Preparation
Adult Leader Meeting (one leader per unit)
Tour of Camp,
Flag Lowering
DINNER
MANDATORY BB/Archery Safety Session
Program activities to be announced
Campfire
Campsite – Lights out
Day 2
7:00 AM
7:30 AM
7:30 AM – 8:30AM
8:45 AM – 9:45 AM
10:00 AM – 11:00 AM
11:15 AM – 12:15 PM
12:15 PM – 1:00 PM
1:00 PM
1:15 PM – 2:15PM
2:30 PM – 3:30 PM
3:45 PM – 4:45 PM
5:00 PM – 5:45 PM
5:50 PM
6:00 PM - 6:45 PM
6:50 PM -7:00 PM
7:15 PM – 8:15 PM
9:00 PM – 9:45 PM
10:00 PM
Reveille
Flag Raising
BREAKFAST
Session 1
Session 2
Session 3
LUNCH
Leader Meeting(1 per unit)
Session 4
Session 5
Session 6
Program Activities to be announced
Flag Lowering
DINNER
Interfaith Worship at Chapel
Program activities to be announced
Campfire
Campsite – Lights out
Day 3
7:00 AM
7:30 AM
7:30 AM – 8:30AM
8:45 AM – 9:45 AM
10:00 AM – 11 AM
11:15AM – 12:15PM
12:15 PM – 1:00 PM
1:15 PM – 2:15 PM
2:30 PM – 3:30 PM
3:45
4:00 PM
Reveille
Flag Raising
BREAKFAST
Session 1
Session 2
Session 3
LUNCH
Session 4
Session 5
Closing Program
Tear Down Camp / pack up / check out /
Hand in evaluations
Patches, activity sheets and health forms are given at check-out.
Youth Showers Open from 7:00 AM to 10:00 PM
Adult Showers Open from 10:00 PM to 7:00 AM
Program offerings
Cub scouts (TIGERS, wolves & bears)
To ensure each Cub Scout has a well-rounded camp experience, our 8:30 a.m. to 12 p.m. and 1:30 p.m. to
5:00 p.m. program rotations will be done in a round robin. Cub Scouts will have a chance to visit each
program area.
Webelos
Webelos are invited to explore the galaxy of Little Sioux Scout Ranch with us through a variety of treks!
 “To Boldly Go…” Trek (High Adventure)
o Webelos will use/learn outdoor skills as they explore areas of camp other Cub Scouts
have never gone (Recommended for Webelos 2).
o Earn Outdoorsman Activity Badge, Map & Compass Belt Loop & Pin, Hiking Belt Loop &
Pin, Fishing Belt Loop and work on the “Swing” requirements for the NOVA award.
 Bridges, Circuits & Secret Codes Trek (Engineer)
o High-tech/Curious Webelos delve into electrical circuits, bridges and cryptography in this
engineering trek.
o Earn your Engineering Activity Badge, Math Belt Loop, and the “Tech Talk” and “1-2-3 Go”
requirements for the NOVA award.
 “Exploring Our Macrocosm” Trek (Forester, Naturalist, Geologist)
o This band of Webelos will study the forestry, nature and geology of planet Earth and learn
ways to conserve our home.
o Earn your Forester, Naturalist and Geologist Activity Badges, Map & Compass Belt Loop,
Geology Belt Loop, Hiking Belt Loop, and Wildlife Conservation Belt Loop & Pin.
 Galactic Olympics Trek (Sportsman)
o Space Athletes will train and compete in a variety of events, learn about levers and show
out-of-this-world sportsmanship.
o Earn your Sportsman Activity Badge, Soccer Belt Loop, Ultimate Frisbee Belt Loop, and
work on the “Swing” requirements for the NOVA award.
 Mission Control Trek (Scientist)
o Learn about how air/water/atmospheric pressure effect life.
o Conduct experiments on this third rock from the sun!
o Earn your Scientist Activity Badge, Science Belt Loop and work on the “Science”
requirements for the NOVA award.
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Special program notes
Other activities open to Bears, Wolves and Webelos include BB guns, archery, the LSSR waterslide,
STEM/NOVA activities, nature events, craft activities, open rowboating, open fishing, and a star search and
night hike.
 Shooting Sports: We offer two ranges:
o BB Gun Range: Scouts will learn rifle safety: how to shoot BB guns, and they can earn the
BB Gun Belt Loop and BB Gun Pin.
o Archery Range: Scouts will learn how to properly shoot a bow and arrow at our Archery
Range. They can earn the Archery Belt Loop and Archery Pin.
 Nature
o Scouts will go on a nature hike and learn about some of the flora and fauna of Little Sioux
Scout Ranch.
 Swimming
o Swimming is not permitted in the lake. As we work to develop Cub Scout Resident Camp
in years to come, and also develop the property and facilities at Little Sioux Scout Ranch,
we will be working to incorporate an unparalleled aquatics experience.
 Open Fishing
o You may bring your own equipment to fish during free time. The dining pavilion will not
cook or clean any fish caught. Scouts are encouraged to practice catch and release fishing
with fly or spin fishing equipment and to use barbless hooks.
o Scouts are not required to have a fishing license.
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CAMP MAP
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Departure from camp
Evaluations
Each adult leader will be given an evaluation form. Please take the opportunity to fill out the evaluation form
and return it before you leave camp. Your feedback is valuable to our camp staff. We appreciate your
comments, concerns, and opinions. Adult leaders who are only staying for a portion of the three days should
fill out an evaluation before they depart. Evaluation forms will be available and can be turned in at the LSSR
camp office. Patches and a list of all advancements & achievements will be given out upon return of the
evaluation form.
Camp site clean-up and Check-out:
Time will be allotted for campers to pack up camp and load vehicles. We ask that leaders do not deprive
boys of program time in an effort to get packed up early. Camp staff will be available and willing to help
campers move their gear from the campsite to the parking lot. With all of us working together this process
can be completed smoothly and quickly. Remember “Leave No Trace.” All Scouts in a campsite will check
out together to ensure the site is ready for the following week of camp.
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Camp policies
Staff Responsibilities
Each campsite will have a camp staff member familiar with the program, camp layout, and camp policies.
He or she will be a registered member of the BSA, and will be your group's primary resource for a quality
camp experience. This person is to be your support for your program, not to provide adult leadership and
discipline. The same holds true for all staff members.
Camper Discipline
Discipline is the responsibility of the adult leadership attending with the Pack. The camp staff is available to
help with, but not take over, any discipline problem. Under no circumstances is corporal punishment
allowed. Take all serious discipline problems to the Camp Director, working through your assigned camp
staff member. The Camp Director reserves the right to remove any person from camp who may present a
threat to any camp staff or attendees, or to camp property.
Alcohol and Drugs:
There are absolutely no alcoholic beverages or unapproved drugs allowed in, or to be consumed at, camp.
Anyone violating this policy will be asked to leave immediately and, if applicable, the appropriate law
enforcement agency will be contacted. Prescription drugs need to be checked in by the camp’s Health
Officer and noted on your health form.
Tobacco Usage
Tobacco usage is not allowed at camp. If it is legal for you to use tobacco and you must do so, you must
secure permission from the Camp Director and follow strict directions on where and when it is appropriate.
KniveS
Boys must have a "Whittling Chip" or “Totin’ Chip” card to use a knife at camp. This card can be earned at
camp, so the knife must not be used until it is earned. Blades may not be longer than four inches and must
fold. Sheath knives are not permitted.
Personal Shooting Sports Equipment
All personal firearms, ammunition, and archery equipment must be left at home. LSSR will provide all
necessary shooting sports equipment.
Pets and Wildlife:
No pets allowed. Camp abounds with wildlife. Do not attempt to touch or feed any wildlife. Report any
wildlife that behaves in a strange manner to a staff member. This includes showing no fear of humans,
biting, scratching, etc.
Liquid Fuels
All liquid fuels present a potential safety and fire hazard. They should never be inside a tent. Only adults
can use liquid fuels in camp.
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Flames in Tents
There will be no flames or heating elements of any kind in tents. All tents must have appropriate firedousing materials nearby; the camp will provide these.
Registered BSA Members
All campers must be registered members of the BSA before attending camp. All adult leaders attending
camp must be registered with the Boy Scouts of America or the parent/guardian of the child they are
attending with. This should be completed by June 1, 2013 when the pack rosters are submitted to the
Camp Director.
All un-registered parents must have taken Youth Protection on-line, and bring a certificate of completion to
camp to turn in at check-in.
Siblings
There is no program for non-Scout siblings at camp. Please make arrangements for them to stay with
family or friends.
Uniforms
All campers are encouraged to wear a camp shirt for breakfast and dinner every day. This could include a
Resident Camp T-shirt. The Cub Scout uniform shirt with appropriate neckerchief is the expected dress for
flag ceremonies.
Electronic Devices
These devices are not needed in camp. If a radio is needed, it must have headphones. Hand-held video
game devices are discouraged due to their significant program distraction.
Parking
All vehicles must be parked in the designated lot. Unapproved vehicles will not be allowed beyond the
parking area. Please back your vehicles in when parking, if you are able. In case of an emergency, this will
allow for easy evacuation.
Trading Post
The trading post will carry Cub Scout supplies, handicraft material, souvenirs, sundries, snacks, candy, and
soft drinks.
Cleanliness
Campsites and facilities will be clean and ready upon your arrival at camp. Leaders are responsible for the
cleanliness of their campsites, latrines, tents, and Cub Scouts in their unit during your stay at camp. Please
help Cub Scouts remember to wash their hands before meals.
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Lost & Found
Please mark all belongings with name, city, and pack number. Lost and found is the responsibility of the
Quartermaster. Items not claimed within 30 days will be given to a charitable organization.
Weather
The weather at LSSR is unpredictable throughout the summer months. Everything from warm summer
days, thunderstorms, and cold nights are considered normal. Be prepared. Don't forget coats, rain gear,
and warm sleeping bags rated to at least 20 degrees, or bring an extra blanket. Check the forecast before
leaving for camp at www.weather.com or another reputable meteorology site.
Other important rules to know
 Open-toe sandals and flip flops are not permitted in camp. This is for your safety and protection.
 Any form of bullying, hazing, ridicule, or fighting is unacceptable and may result in expulsion from
camp.
 Shower facilities are regulated to ensure no adults and youth will use them at the same time.
 All Scouts and adults must carry a water bottle or hydration pack at all times.
 Scouts are required to use the “buddy” system when traveling through camp.
 One-on-one adult supervision is strictly enforced in the lake area and is checked regularly by
lifeguards, leaders and staff.
 Adult leaders must supervise all campfires.
 Profanity is unbecoming of a Scout or Scouter and is not tolerated at camp.
 Sign in and sign out procedures are required. All visitors need to sign in and out through the Camp
Office.
 Adult leaders must report any suspicion of abuse to the Camp Director immediately.
 If you need to enter a Scout’s sleeping area, before entering, announce your presence first and
make sure another adult accompanies you.
 In the shower areas, in the event you feel it necessary to enter while a Scout is in the facility due to
a behavior issue or possible injury, you may enter only when accompanied by another adult.
 Anyone caught stealing or vandalizing will be expelled from LSSR and the unit will be responsible
for providing compensation to the individual/unit/camp.
Contact information




Camp Director: Kara Dacey, (402) 731-1324 or [email protected]
Program Director: Sheryl Oakman, (402) 490-6138 or [email protected]
Camp Ranger: Doc Schaefer, (402) 910-0854.
Durham Scout Center: (402) 431-9BSA (9272).
- 18 -
See you at camp!
- 19 -
Parte A Nombre completo
Fecha de nacimiento Alergias
Teléfono en caso de emergencia
Part A Full name:_________________________________DOB:________________ Allergies:___________________ Emergency contact No.:______________
Annual Health and Medical Record
Registro Médico y de Salud Anual
Part A/Parte A
High-adventure base participants:
Participantes en la base de aventura extrema:
Expedition/crew No.
Expedición/grupo no.:_______________________________
or staff position
o puesto fijo: ______________________________________
GENERAL INFORMATION/INFORMACIÓN GENERAL
Name ____________________________________________________ Date of birth ___________________________________ Age ____________ Nombre Fecha de nacimiento (MM/DD/Year) - (MM/DD/Año) Edad Male Masculino
Female
Femenino
Address ______________________________________________________________________________________________ Grade completed (youth only)______________________
Domicilio
Grado escolar completado (sólo niños)
City __________________________________________________________ State______________ Zip ______________________ Phone No. _______________________________
Ciudad Estado Código postal No. telefónico
Unit leader ____________________________________________________ Council name/No. ___________________________________________ Unit No. ___________________
Líder de la unidad Nombre y no. del concilio No. de unidad
Social Security No. (optional; may be required by medical facilities for treatment)___________________________________ Religious preference ________________________
No. de Seguro Social (opcional; puede ser solicitado por las instalaciones médicas para brindar tratamiento) Preferencia religiosa
Health/accident insurance company ____________________________________________________________ Policy No. ________________________________________________
Compañía de seguro médico/accidental No. de póliza
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF YOU DO NOT HAVE MEDICAL INSURANCE, ENTER “NONE” ABOVE.
ANEXAR UNA FOTOCOPIA DE AMBOS LADOS DE LA TARJETA DEL SEGURO. SI USTED NO TIENE SEGURO MÉDICO, ESCRIBA “NINGUNO.”
In case of emergency, notify/En caso de emergencia, notificar a:
Name _________________________________________________________________________________ Relationship ____________________________________________________
Nombre Parentesco
Address _______________________________________________________________________________________________________________________________________________
Domicilio
Home phone _________________________________________ Business phone _____________________________________ Mobile phone _______________________________
Teléfono de casa Teléfono de oficina Teléfono móvil
Alternate contact name _____________________________________________________________________ Alternate’s phone ___________________________________________
Nombre de contacto alterno Teléfono del contacto alterno
HEALTH HISTORY/HISTORIAL MÉDICO
Please fill in the bubbles as indicated below:
Por favor rellene los círculos tal como se indica a continuación:
Do you currently have, or have you ever been treated for any of the following?
Incorrect:
¿Tiene actualmente, o ha tenido alguna vez los siguientes?
Yes/Sí
No/No
Incorrecto
Condition/Padecimiento
Asthma
Asma Diabetes
Diabetes Correct:
Correcto
Explain/Explique
Last attack: (MM/YY)
Último ataque: (MM/AA)
%
Last HbA1c: (Percentage)
Última HbA1c: (Porcentaje)
Hypertension (high blood pressure)
Hipertensión (presión alta)
Heart disease/heart attack/chest pain/heart murmur
Enfermedad del corazón/infarto/dolores de pecho/soplo cardíaco
Stroke/TIA
Apoplejía/Accidente isquémico transitorio
Lung/respiratory disease
Enfermedades pulmonares/respiratorias
Ear/sinus problems
Problemas del oído/senos paranasales
Muscular/skeletal condition
Condiciones musculares/óseas
Menstrual problems (women only)
Problemas menstruales (sólo mujeres)
Psychiatric/psychological and emotional difficulties
Dificultades psiquiátricas/psicológicas y emocionales
Behavioral/neurological disorders
Trastornos de conducta/neurológicos
Bleeding disorders
Enfermedades hemorrágicas
Fainting spells
Desmayos
Thyroid disease
Enfermedades de la tiroides
Kidney disease
Enfermedades del riñón
Sickle cell disease
Anemia falciforme
Seizures
Last seizure: (MM/YY)
Convulsiones Última convulsión: (MM/AA)
Sleep disorders (e.g., sleep apnea)
Trastornos del sueño (por ejemplo, síndrome de apnea-hipopnea durante el sueño)
Use CPAP: Usa CPAP
Yes
Sí
No
No
Abdominal/digestive problems
Problemas abdominales/digestivos
Surgery
Cirugía
Last surgery: (MM/YY)
Última cirugía: (MM/AA)
Serious injury
Lesión grave
Excessive fatigue or shortness of breath with exercise
Fatiga en exceso o dificultad para respirar al hacer ejercicio
Other
Otro
Page 1 of 2
PART A (continued on next page)
HEALTH HISTORY/HISTORIAL MÉDICO
Please fill in the bubbles as indicated:
Are you allergic to or do you have any adverse reaction to any of the following?
Por favor rellene los círculos tal como se indica:
¿Es alérgico a, o le causa alguna reacción adversa cualquiera de los siguientes?
Yes/Sí
Correct:
IncorrectoCorrecto
Explain
Allergies or Reaction to
No/No
Incorrect:
Alergias o Reacciones a
Explique
Medication
Medicamentos
Food, plants, or insect bites
Alimentos, plantas o picaduras de insectos
The following immunizations are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. For each
item, indicate if you have been immunized, the date of the immunization (MM/YY), if you have had the disease, and the date (MM/YY).
BSA recomienda las siguientes vacunas. La vacuna contra el Tétanos es obligatoria y debe haberla recibido en los últimos 10 años. Por cada punto, indique si ha sido vacunado, la fecha
en que la recibió (MM/AA), si ha padecido la enfermedad, y la fecha (MM/AA).
Immunized?
Immunizations
¿Vacunado?
Yes/Sí
Date (MM/YY)
Fecha (MM/AA)
Vacunas
No/No
Had Disease?
Date (MM/YY)
¿La ha padecido?
Yes/Sí
Fecha (MM/AA)
No/No
Tetanus
Tétano
Pertussis
Part A Full name: __________________________________________________________ DOB: ____________________
Parte A Nombre completo Fecha de nacimiento
Tos ferina
Diphtheria
Difteria
Measles
Sarampión
Mumps
Paperas
Rubella
Rubéola
Polio
Polio
Chicken pox
Varicela
Hepatitis A
Hepatitis A
Hepatitis B
Hepatitis B
Meningitis
Meningitis
Influenza
Influenza
Other (i.e., HIB)
Otra (por ejemplo, HIB)
Exemption to immunizations claimed (form required).
Exención de vacunas solicitada (formulario obligatorio).
MEDICATIONS List all medications currently used. (If additional space is needed, please photocopy this part of the
health form.) Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only.
MEDICAMENTOS Enumere todos los medicamentos que usa en la actualidad. (Si requiere espacio adicional, favor de sacar una fotocopia de esta
parte del formulario.) Se debe incluir información sobre inhaladores y EpiPen, incluso si son sólo para uso ocasional o en caso de emergencia.
Medication Medicamento__________________________________________
Strength Frequency
Dosis _____________________ Frecuencia _________________
Strength Frequency
No medications
Sin medicamentos
Additional medications (sheet attached)
Medicamentos adicionales (hoja anexa)
Strength Frequency
Approximate date started Approximate date started Approximate date started Reason for medication
Reason for medication
______________________________________________________
______________________________________________________
______________________________________________________
Medication Medication Medication Fecha aproximada de inicio______________________________
Razón del medicamento_________________________________
Medicamento__________________________________________
Strength Frequency
Fecha aproximada de inicio______________________________
Medicamento__________________________________________
Strength Frequency
Medicamento__________________________________________
Strength Frequency
Approximate date started Approximate date started Approximate date started Reason for medication
______________________________________________________
______________________________________________________
______________________________________________________
Administration of the above medications
is approved by (if required by your state):__________________________________________________________/________________________________________________________
La administración de los medicamentos arriba
Parent/guardian signature
and/or
mencionados está aprobada por (si lo requiere su estado)
Firma del padre o tutor
y/o
MD/DO, NP, or PA signature
Firma del Dr., Enfermera
profesional, Asistente médico
Bring enough medications in sufficient quantities and in the original containers. Make sure that they are NOT expired, including inhalers
and EpiPens. You SHOULD NOT STOP taking any maintenance medication unless instructed to do so by your doctor.
Asegurarse de traer los medicamentos en cantidades suficientes y en los envases originales. Asegurarse de que NO ESTÉN
CADUCADOS, incluyendo inhaladores y EpiPens. NO DEBE DEJAR DE tomar cualquier medicamento de mantenimiento a menos
que se lo indique su médico.
Page 2 of 2
680-001
2012 Printing
Rev. 9/2012
High-adventure base participants:
Participantes en la base de aventura extrema:
Part B Full name: __________________________________________________________ DOB: ____________________
Parte B Nombre completo Fecha de nacimiento
Part B/Parte B
Expedition/crew No./Expedición/grupo no.: _______________________________
or staff position/o puesto fijo: ____________________________________________
Informed Consent and Release Agreement
NOTIFICACIÓN DE CONSENTIMIENTO Y EXONERACIÓN DE RESPONSABILIDAD
I understand that participation in Scouting activities involves
a certain degree of risk and can be physically, mentally, and
emotionally demanding. I also understand that participation in
these activities is entirely voluntary and requires participants to
abide by applicable rules and standards of conduct.
Entiendo que la participación en actividades Scouting implica un cierto
grado de riesgo y que pueden ser física, mental y emocionalmente
agotadoras. Asimismo, entiendo que la participación en dichas actividades
es completamente voluntaria y requiere que los participantes se acaten a
las reglas y estándares de conducta pertinentes.
In case of an emergency involving me or my child, I understand
that every effort will be made to contact the individual listed as the
emergency contact person. In the event that this person cannot
be reached, permission is hereby given to the medical provider
selected by the adult leader in charge to secure proper treatment,
including hospitalization, anesthesia, surgery, or injections of
medication for me or my child. Medical providers are authorized to
disclose protected health information to the adult in charge, camp
medical staff, camp management, and/or any physician or health
care provider involved in providing medical care to the participant.
Protected Health Information/Confidential Health Information (PHI/
CHI) under the Standards for Privacy of Individually Identifiable
Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq.,
as amended from time to time, includes examination findings,
test results, and treatment provided for purposes of medical
evaluation of the participant, follow-up and communication with
the participant’s parents or guardian, and/or determination of the
participant’s ability to continue in the program activities.
En caso de que yo, o mi hijo, nos veamos involucrados en un caso de
emergencia, entiendo que se hará todo lo posible para contactar al
individuo mencionado como persona a contactar en caso de emergencia.
En caso de que dicha persona no pueda ser localizada, por este medio
otorgo permiso al proveedor de servicios médicos seleccionado por el
líder adulto a cargo para asegurar que se proporcione el tratamiento
adecuado, incluyendo hospitalización, anestesia, cirugía o inyecciones
de medicamentos para mí o mi hijo. Los proveedores médicos están
autorizados a compartir información médica protegida con el adulto
a cargo, el personal médico del campamento, la administración del
campamento, o cualquier médico o proveedor de servicios médicos
involucrado en la administración de atención médica al participante. La
Información médica protegida/Información médica confidencial (PHI/CHI,
por sus siglas en inglés) bajo los Estándares de privacidad de información
médica individualmente identificable, 45 C.F.R. §§160.103, 164.501, etc.,
y siguientes como se enmiendan de vez en cuando, incluye resultados
de reconocimientos médicos, resultados de pruebas y tratamiento
proporcionado para propósitos de evaluación médica del participante,
seguimiento y comunicación con los padres o tutor del participante,
y determinación de la habilidad del participante de continuar con las
actividades del programa.
I have carefully considered the risk involved and give consent for
myself and/or my child to participate in these activities. I approve
the sharing of the information on this form with BSA volunteers
and professionals who need to know of medical situations that
might require special consideration for the safe conducting of
Scouting activities.
I release the Boy Scouts of America, the local council, the activity
coordinators, and all employees, volunteers, related parties, or
other organizations associated with the activity from any and all
claims or liability arising out of this participation.
He considerado cuidadosamente el riesgo implicado y he dado el
consentimiento para mí mismo o mi hijo de participar en dichas
actividades. Apruebo que se comparta la información contenida en este
formulario con los voluntarios y profesionales de BSA que necesiten tener
conocimiento de condiciones médicas que puedan requerir consideración
especial para la realización de actividades Scouting de manera segura.
Eximo a Boy Scouts of America, al concilio local, a los coordinadores de la
actividad y a todos los empleados, voluntarios, grupos involucrados u otras
organizaciones asociadas con la actividad, de cualquier y toda reclamación
o responsabilidad que surja a raíz de esta participación.
Without restrictions./Sin restricciones.
With special considerations or restrictions (list)/Con condiciones especiales o restricciones (lista):
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
I hereby assign and grant to the local council and the Boy Scouts
of America the right and permission to use and publish the
photographs/film/videotapes/electronic representations and/or
sound recordings made of me or my child at all Scouting activities,
and I hereby release the Boy Scouts of America, the local council,
the activity coordinators, and all employees, volunteers, related
parties, or other organizations associated with the activity from any
and all liability from such use and publication.
Por este conducto asigno y otorgo al concilio local y a Boy Scouts of
America el derecho y permiso para usar y publicar las fotografías/películas/
videocintas/representaciones electrónicas y grabaciones de sonido de mí
o mi hijo realizadas en todas las actividades Scouting, y por este medio
exonero a Boy Scouts of America, al concilio local, a los coordinadores
de la actividad y a todos los empleados, voluntarios, grupos involucrados
u otras organizaciones asociadas con la actividad, de cualquier y toda
responsabilidad por dicho uso y publicación.
I hereby authorize the reproduction, sale, copyright, exhibit,
broadcast, electronic storage, and/or distribution of said
photographs/film/videotapes/electronic representations and/
or sound recordings without limitation at the discretion of the
Boy Scouts of America, and I specifically waive any right to any
compensation I may have for any of the foregoing.
Por este conducto autorizo la reproducción, venta, derechos reservados,
exhibición, transmisión, almacenamiento electrónico y distribución de
dichas fotografías/películas/ videocintas/representaciones electrónicas
y grabaciones de sonido sin limitación a discreción de Boy Scouts
of America, y específicamente renuncio a cualquier derecho de
compensación alguna que pueda tener por cualquiera de lo anterior.
Yes/Sí
No/No
Page 1 of 2
PART B (continued on next page)
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS:
You must designate at least one adult. Please include a
telephone number.
ADULTOS AUTORIZADOS PARA TRANSPORTAR AL NIÑO HACIA Y DESDE
LOS EVENTOS:
Debe designar por lo menos a un adulto. Por favor incluya un número telefónico.
1. Name/Nombre___________________________________________________________________________Telephone/Teléfono _________________________
2. Name/Nombre___________________________________________________________________________Telephone/Teléfono_________________________
Adults NOT authorized to take youth to and from events/Adultos NO autorizados para transportar al niño hacia y desde los eventos:
1. Name/Nombre ___________________________________________________________________________Telephone/Teléfono_________________________
2. Name/Nombre ___________________________________________________________________________Telephone/Teléfono_________________________
Part B Full name: __________________________________________________________ DOB: ____________________
Parte B Nombre completo Fecha de nacimiento
I understand that, if any information I/we have provided is
found to be inaccurate, it may limit and/or eliminate the
opportunity for participation in any event or activity.
Entiendo que, si cualquier información que he/hemos proporcionado
es errónea, puede limitar o eliminar la oportunidad de participación en
cualquier evento o actividad.
If I am participating at Philmont, Philmont Training Center,
Northern Tier, Florida Sea Base, or the Summit Bechtel
Reserve: I have also read and understand the risk advisories
explained in Part D, including height and weight requirements
and restrictions, and understand that the participant will
not be allowed to participate in applicable high-adventure
programs if those requirements are not met. The participant
has permission to engage in all high-adventure activities
described, except as specifically noted by me or the healthcare provider. If the participant is under the age of 18, a parent
or guardian’s signature is required.
Si participo en Philmont, el Centro de Capacitación Philmont,
Northern Tier, la Base Marina de la Florida o Summit Bechtel Reserve:
También he leído y entiendo las advertencias de riesgo explicadas
en la Parte D, incluyendo los requisitos y restricciones de estatura y
peso, y entiendo que al participante no se le permitirá intervenir en
programas de aventura extrema si dichos requisitos no se cumplen.
El participante tiene permiso de intervenir en todas las actividades
de aventura extrema descritas, excepto aquellas específicamente
señaladas por mí o el proveedor de servicios médicos. Si el
participante es menor de 18 años, se requiere la firma de el padre/
madre o tutor.
Participant’s name/Nombre del participante______________________________________________________________________________________________
Date/Fecha
Participant’s signature/Firma del participante
Parent/guardian’s signature/Firma del padre o tutor
(if participant is under the age of 18/si el participante es menor de 18 años)
Second parent/guardian signature/Firma del otro padre o tutor
(if required; for example, CA/si se requiere; por ejemplo en CA)
Date/Fecha
Date/Fecha
This Annual Health and Medical Record is valid for 12 calendar months.
Este Registro Médico y de Salud Anual tiene vigencia por 12 meses calendario.
Page 2 of 2
680-001
2012 Printing
Rev. 9/2012
Campership Request
Council Summer Program
2013 Campership Application Deadlines:
Boy Scout Camp at Camp Cedars - March 1, 2013
Cub Scout Camps – 1 months prior to event
Mail or transmit to:
Mid-America Council, Boy Scouts of America
12401 West Maple Road
Omaha, NE 68164-1853
Purpose: The purpose of the council campership program is to make summer camp available to deserving Scouts who
could not otherwise afford the attendance fees. This program is not intended to provide all of the camp fees. Paying
a boy’s way to camp is a joint effort of the Troop, the Scout and his family, and the campership program. Details of
the application are confidential. This application MUST be signed by the parent(s) and Scoutmaster of the Scout
requesting the campership.
Campership application for:
Name: _____________________________________________ Unit Type/#: _______________ District: ________________
Address: _____________________________________________ City: ____________________ State: ____ Zip: __________
Phone: __________________ Age: _____ Camp: _________________________________ Dates: ______________________
Name of event: _________________________________________________________________________________________
Please provide a brief explanation for your request: _________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Total Number in Household ________ (How many under 18?) _______Total Yearly Family Income $ __________________
Unit Participation in FOS
Yes
No
Youth Participation in Popcorn Sales
Yes
No
Council camp fee: $___________ Chartered partner will contribute: $___________ Unit will contribute: $____________
Have you applied for camperships with us in the past?
Yes
No
If Yes, what year(s)? ________________
I, ______________________________________ certify I have personally talked with this Scout regarding his attendance
(Cub/Scoutmaster)
at camp and have verified the need for a Campership with his parents or guardians.
Cub/Scoutmaster’s Email: ______________________________________Phone: ________________ Date: _____________
Parent/Guardian signature (required): ________________________________ Email: _____________________________
Address: _____________________________________________ City: ____________________ State: ____ Zip: __________
(If different from Scout’s information)
For Office Use Only
Date received: ________________________ Approved?
Yes
No Staff Advisor signature: ________________________
Approved amount of $______________________________ has been credited to your unit camp fee for the current year.
General Information
Please read carefully
1. All Campership applications must be submitted by March 1st for Boy Scouts and one months prior to camp for Cub
Scouts.
2. All Campership applications must be filled out COMPLETELY and ACCURATELY or they will be returned.
3. Any application received without a brief explanation of why it is being requested will be returned so they can be
completed; if they are received a second time without an explanation the Campership will be denied.
4. Letters will be sent to the Unit leaders notifying them if a campership was granted and in what amount.
5. All youth using council facilities whether for short-term overnight or long-term summer camp periods are already
subsidized, in part, by the council’s yearly operating budget which pays for taxes, year-round camp rangers,
maintenance, liability insurance, heat, light, etc. The community through United Way allocations, Friends of Scouting,
popcorn sales, trust fund income and Campership donations pays this cost.
6. No more than 1/3 of the total attendance fee will be granted. Special hardship requests require discussion with the
Campership Committee and the Council Camping Director.
7. All applications are reviewed and approved or disapproved by the Council Campership Committee. This committee is
made up of volunteers from throughout the Mid-America Council.
8. Applications are accepted on an annual request only. A campership cannot be transferred to another camping season
or to another registered Scout.
9. A Scout, who is awarded a campership, but does not attend summer camp, forfeits the campership.
10. Camperships are not granted to adults.
11. The remainder of the camp fee must be paid prior to attending Camp.
12. Camperships are issued only for Mid-America Council camps to Scouts registered in the Mid-America Council.
13. Scouts from units that conduct a FOS campaign and participate in popcorn sales will receive first preference.
2013 Activity Refund Request Form
The Council’s refund policy reads: Fees for all district and council events are transferable to other Scouts within the unit.
If approved, a refund will be deposited in the Unit Pre-Paid Account (UPPA) only for individuals, groups, or units that
cancel an event reservation prior to the event. There will be no refunds under $10.00. Refunds will only be considered if
one of the following circumstances applies.
Circumstances considered (You must provide supporting documentation (approvals will not exceed 80%)):
□
□
□
Sickness or injury
Death in immediate family
Relocation outside Mid-America Council borders
Name _____________________________________________□ Youth□ Adult Date of Request__________________
District ____________________ Unit_________ Unit# ______ Fee Paid $_____________ Registration # ____________
Activity ________________________________________Date(s) ______________ Location ______________________
I understand, if this request is approved, the refund will be posted to the UPPA by October 1, 2013 (assuming the unit
does not owe a balance on any other Council activities).
Committee Chair signature ___________________________ Phone (____) ____-_______email ____________________
This request must be submitted to:
Program Assistant, Mid-America Council
12401 W Maple Rd, Omaha, NE 68164
Fax: (402) 431-0444
[email protected]
FOR DURHAM SCOUT CENTER OFFICE ONLY
Date Received ________________________ Date Reviewed _______________________ Accepted _____ Denied _____
Authorized by ____________________________________________________________________ Refund % _________
Explanation (if denied) _______________________________________________________________________________
Amt posted to UPPA $_____________ Date posted ____________Request Completed By: ________________________
Special Needs / Dietary Request Form
Submit AT LEAST 2 WEEKS BEFORE START of Camp/Event
If you have a need that requires special attention due to medical or religious reasons, fill out this request form and submit to the
Durham Scout Center at 12401 West Maple Rd, Omaha, NE 68164 or fax to (402) 431-0444 or email [email protected] .
Please submit the completed form a minimum of two weeks before the person will be attending camp/event.
Name: ____________________________________________________ Pack/Troop #_________________ Date: ________________
Name of event: ______________________________________________Dates of event: ________________ to _________________
Location of Event: _____________________________________________________________________________________________
We ask individuals requiring a very special diet (please use this option only if medically necessary or required by religion) to bring
their own food to camp. Camp staff can store and help prepare the food.
I am submitting this form because I or a Scout coming with me (please check all that apply)…
 Needs a CPAP
 Has a special diet (please answer the questions below)
 Has an allergy (please answer the questions below)
 Has a medical condition
 Needs special arrangements (please answer the questions below) i.e. sleeping arrangements, medicine storage,
transportation around camp, etc.
ALLERGIES:
Please name the allergen (i.e. Peanuts):____________________________________________________________________________
What is the trigger for a reaction to the allergen, please check all that apply:
Person has a negative reaction when the allergen is within ___ feet of the person: ____
Person has a negative reaction when they come into physical contact with the allergen: ____
Person has a negative reaction only when ingesting or eating the allergen: ____
Please tell what reaction happens when the person comes into contact with this allergen: __________________________________
____________________________________________________________________________________________________________
MEDICAL CONDITION:
Please describe below in as much detail as possible the medical condition and special need. _________________________________
____________________________________________________________________________________________________________
SPECIAL DIETARY NEEDS:
Please describe dietary requests such as special food storage or vegan diets here. _________________________________________
____________________________________________________________________________________________________________
OTHER SPECIAL NEEDS OR REQUESTS:
Please share other special arrangements or needs here not mentioned previously (please be specific). _________________________
____________________________________________________________________________________________________________
Camp Management
See you at camp!
- 19 -

galactic trek - Scouting Event

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