PEACE
Camper’s name:
____________________________________________ Nickname:
______________________________
Last
Name Middle Name First Name
Address:
_________________________________________________________________________________________
City: __________________________________________ State: __________ Zip: __________
Home Phone: (_____) ______________________ E-mail: _____________________________________________
Legal guardian (if under 18): ___________________________________________________________________________
Address: __________________________________________________________________________________________
City: _______________________ __________________ State: __________ Zip: ______________________
Home Phone: (_____) ______________________E-mail:
___________________________________________________
Work Phone: (_____) _____________ Cell phone: (_____)
___________________________________________________
Campers birth date: ___/___/___ Age at time of camp:
Grade next Fall: __________________________
Gender (M)_____ (F)_____ T-shirt
size (S)_____ (M)_____ (L)______
(XL) ____ (XXL)___________________
Will you need any special assistance or accommodation?
______________________________________________________
If you have a tent you will be bringing, how many does it
sleep? ________________________________________________
In order to serve our campers better, we need to know if
a camper has been arrested or has been involved with juvenile court. (Let us
emphasize this information alone does not disqualify campers.)
__________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
In the interest of not
excluding any applicant, we established a sliding scale fee. There are no
additional costs for camp participation. The sliding scale is from $175-$300
per camper.
If this scale truly excludes you or your camper, let us
know. We do our best not to exclude any eager young person who wishes to
attend. Often churches, peace groups, environmental groups, civic groups etc.
are willing to sponsor a camper. You might explore these kinds of sources. And
campers have been successful at raising the money to come to camp. In any case,
let us know. Perhaps we can help.
Enclosed is our registration for camp: $________________
Make checks payable to Florida Coalition for Peace & Justice by
Camper Signature: _______________________________ Date:
____________________
Parent or Legal Guardian Signature: __________________________________ Date:
____________________
Florida Coalition for Peace & Justice
Bob Tancig Coordinator
Florida Coalition for Peace and Justice
PEACE CAMP APPLICATION
Nombre de Campista:
________________________________________Apodo: _________________________________
Apellido
Nombre
Dirección:
_________________________________________________________________________________________
Cuidad: __________________________________________ Estado: __________ Zip Code: _________________
Numero de teléfono: (_____) ______________________ E-mail:
______________________________________________
Guardián (si menos de 18):
____________________________________________________________________________
Dirección:
_________________________________________________________________________________________
Cuidad: _______________________ _______________ Estado: __________ ZipCode: ________________________
Numero de teléfono: (_____) ______________________E-mail:
______________________________________________
Teléfono del trabajo: (_____) _____________ ____ Teléfono Celular: (_____)
_______________________________
Fecha de nacimiento del Campista: ___/___/___ Edad: Grado
Escolar: _________________________________
Género (H) ____
(B) _____ Tamaño de camiseta (S)_____ (M)_____ (L)______
(XL) ____ (XXL)___________
¿Necesitará asistencia o
comodidad especial?
___________________________________________________
¿Si usted tiene una tienda que
usted traerá, cuántos duerme?
_____________________________________
Para servir nuestros campistas
mejor, necesitamos saber si un campista ha estado arrestado o ha estado
implicado con la corte juvenil. (Déjenos acentúan que esta información no
descalifica un campista.)_______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
En el interés de no excluir a
cualquier aspirante, establecimos un sistema de pago de escala. No hay costes
adicionales para la participación del campo. La escala de pago es de $175-$300
por el campista. Si esta escala excluye verdaderamente a su hijo/a de ser
campista, déjenos saber. Hacemos lo mejor posible para no excluir a ninguna
persona joven que desee atender. A menudo las iglesias, los grupos de la paz,
los grupos ambientales, los grupos cívicos etc. están dispuestos a patrocinar
un campista. Puede exploran estos grupos, como recursos de patrocinar. Muchos campistas han podido levantar el
dinero para venir al campo con mucho éxito. En cualquier caso, déjenos saber.
Quizás podemos ayudar.
Incluido es nuestro registro
para el campo: $________________ Hagan
los cheques a la coalición de la Florida para la paz y la justicia antes del de
junio 5 de 2005.
Firma de Campista: _______________________________ Fecha:
______________
Firma de padre o guardián legal:
__________________________________ Fecha:
______________
Florida
Coalition for Peace & Justice
Bob Tancig Coordinator
YOUTH PEACE CAMP
2005
MEDICAL
AUTHORIZATION
I hereby
give permission to the staff of The Florida Coalition for Peace and Justice
Youth Peace Camp to authorize emergency treatment for my child in the event
that I can’t be reached.
______________________________________________________________________________________
Signature
of parent or legal guardian (if the applicant is under 18)
Campers
Name: ________________________________________________
Address: ________________________________________________
________________________________________________
Campers
Birthday: ___________________________
Vegetarian: _________ Vegan: ____________
Special
dietary needs or food allergies? ________________________
________________________________________________
Special
Medications: ________________________________________________
________________________________________________
If
taking medications, what are the complete instructions?
_____________________________________________________________________
_____________________________________________________________________
Emergency
Contact: (If parent or legal guardian were unavailable)
Name: _______________________________________________________
Address: _______________________________________________________
_______________________________________________________
Phone
Number ____________________________________
Relationship
to Camper:
______________________________________________________________________
Family
Doctors Name:
______________________________________________________________________
Phone
number: ________________________________________________
Insurance
Company: _________________________________________________
Policy
Number: _________________________________________________
Telephone
Number: _________________________________________________
AUTORIZACIÓN MÉDICA
CAMPO 2005 DE LA PAZ DE LA
JUVENTUD
Autorizo al personal de la
Coalición de Paz y Justicia de Florida y
al Campo de la Paz y Juventud permiso para que traten a mi hijo/hija en caso de
una emergencia si no puedo ser alcanzado.
______________________________________________________________________________________
Firma del padre o del guarda
legal (si el niño/niña tienes menos de 18 anos).
Nombre del Campista: ________________________________________________
Dirección: ________________________________________________
________________________________________________
Cumpleaños d Campista: ________________________________________________
Vegetariano: ___________ Vegan:
_____________
¿Tienes tu niño/niño necesidades
o alergias dietéticas especiales? ___________________
______________________________________________________________________
______________________________________________________________________
Medicamentos especiales:
__________________________________________________
_______________________________________________________________________
¿Si toman medicaciones, cuáles
son las instrucciones completas?
_______________________________________________________________________
_______________________________________________________________________
Contacto De la Emergencia: (si
el padre o el guarda legal no esta disponible)
Nombre:
_______________________________________________________________
Dirección:
______________________________________________________________
_______________________________________________________________________
Número De Teléfono: _________________________________________________
Relación al campista: _________________________________________________
Nombre de Medico: _________________________________________________
Número de teléfono: _________________________________________________
Compañía de seguro: _________________________________________________
Número de seguro: _________________________________________________
Número de teléfono: _________________________________________________
YOUTH PEACE CAMP
QUESTIONNAIRE
Camper Name:
_______________________________________
1.
How did you
hear of Peace Camp?
2.
Have you ever
attended Peace Camp? If so; what did you enjoy most? What did you least enjoy?
3.
Do you have
friends or relatives who have attended Peace Camp?
4.
Do you have
friends or relatives who are also planning to attend?
5.
Why would you
like to attend Peace Camp? What are your reasons?
6.
What do you
expect camp to be like?
7.
What would
you like camp to be like? Do you have any special hopes for Camp?
8.
Have you ever
camped, hiked, used a tent or slept outdoors?
9.
Do you like
to express yourself artistically? Do you play a musical instrument, dance,
write lyric or poetry, act or sing?
10. What are your favorite activities, hobbies, interests
or skills?
11. What gifts or talents will you bring to Peace
Camp?
12. Do you have a favorite sport?
13. What are your favorite meals?
14. What do you know about vegetarian cooking?
15. Can you swim?
16. What languages do you speak?
17. What are your favorite subjects in school?
18. What are your favorite TV programs?
19. Which famous people do you admire most?
20. Which adults in your life do you admire?
21. What kind of work would you like to do when you
are finished with your education?
22. How do you go about promoting peace and justice in
your daily life?
23. Do you have a life’s dream?
24. Campers and staff are expected to abide by all
Peace Camp rules. Do you have any
problems following the guidelines in the “Camper Agreements” included in this
packet?
Florida Coalition for Peace & Justice
Bob Tancig Coordinator
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