Registration Form


3101 Balboa Drive,
San Diego, CA 92103
map & directions

Mail: P.O. Box 3275
San Diego, CA 92163

Ph: 619-291-8985

Fax: 619-291-8988

Email:
campfiresdi@sbcglobal.net

Office Hours:
 Monday-Friday
8:30 am - 5:00 pm

Summer Camp 2008 - Extreme Adventure: June 23rd - August 22nd

Save a stamp and register online or download registration form packet click here
PLEASE NOTE that you must fill out online registration form before paying for camp online. To Pay online using Paypal click here.

Camp Fire USA - SDI
Summer Camp 2008 -
Extreme Adventure: June 23rd - August 22nd
Camper Packet
Camper Information
Name:
Birthday: (xx/xx/xxxx)
Address:
City:
State:   
  Zip:
Home Phone:
 
Age at Camp
Grade in Fall
Parent / Guardian Information
Parent/ Legal Guardian 1
Address:
Address2:
City:         
State:
    Zip:
Work Phone
Cell Phone
Home Phone
Parent/ Legal Guardian 2
Address:
Address2:
City:         
State:
    Zip:
Work Phone
Cell Phone
Home Phone
Emergency Contacts -
Parents will always be notified first in case of an emergency
Name
Work Phone
Cell Phone
Relationship to Camper
Name
Work Phone
Cell Phone
Relationship to Camper
Name
Work Phone
Cell Phone
Relationship to Camper
Additional Authorized Pick-UPS - The following are authorized to pick up your camper.
They will be required to show ID.
Name
Work Phone
Cell Phone
Relationship to Camper
Name
Work Phone
Cell Phone
Relationship to Camper
Demographics - Optional completed information helps CFUSA to provide accurate information to community funders
Camper Ethnicity
Household Structure
Annual Household Income
Camper T-shirt Size
Youth:
Adult:
Friend Request (Must be in the same grade)
Friends Name:

Camp Cahito Health History Form

Form will not be processed if form is incomplete. Dates MUST be given or camper’s immunization record must be attached to this form at the time it is submitted in order for form to be complete.
Camper's Name:
Is the participant covered by family medical/hospital insurance?
Group Number:
Vaccine Dates: Mo/Yr Which is the following has
participant had?
DTP:
Measles
TD (tetanus/diphtheria):
 Chicken Pox
Tetanus:
 German Measles
Polio:
 Mumps
MMR:
 Hepatitis A
Influenza B:
 Hepatitis B
Hepatitis B:
    
Varicella
(chicken pox):
    
TB Mantoux Test
Date of last test Result: Pos Neg

Has/does the participant: Allergies:
Had any recent injury, illness, and/or infectious disease?
No
 Food

Have a chronic or recurring illness/condition?
No
 Insects
Have frequent headaches?
No
 Medications
Wear glasses, contacts or protective eyewear?
No

Plants
Have any hearing loss or use a
hearing aid?
No
 Other
Have problems with diarrhea/constipation?
No		 Explain reaction and medications
Have hay fever?
No		 Have ADD/ADHD?
No
Ever passed out during or after exercise?
No
 Have asthma?
No

Have heart problems?
No

  
Explain any “yes” answers.
List any known physical, mental, social difficulties that may effect participation and/or for which special consideration should be given.
List any medications in use
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Camp Cahito Reach-Out Challenge Course
Participant Release Form
Participant Information:
Participant Name:
Address:
Address 2:
Gender:
  
Parent/Legal Guardian :
Parent/Legal Guardian 2 :
Emergency Contacts
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name of Family Physician:
Family Medical Insurance:
ID number:
Employer through which insurance is received:
If participant has been under the care of a physician within the past 12 months or if there are any questions about activity restrictions, attach a statement from a physician indicating restrictions and noting any pertinent recommendations.
Any operations, serious injuries, or chronic illnesses?
If yes, please specify:
Explain reactions/medication:
Indicate any known allergies?
Indicate any known allergies:
 Food: Drugs: Plants: Animals:
Insects: Other:
Indicate year of last immunization:
  Tetanus: Rubella: Diphtheria: Hepatitis:
  Measles: Polio:
 Chicken Pox:  
  Other:
List date of any communicable diseases:

List any medications currently in use, including insulin
List any known physical, mental, social difficulties, or other specific information which may affect participation and/or for which special consideration should be given.
I give authorization for me and/or my child to participate in the Reach-Out Challenge Course held at Camp Fire USA’s Camp Cahito at 3101 Balboa Drive, San Diego, CA 92103. I acknowledge that under certain circumstances the activity could be dangerous and that I am not, nor is my child, required to participate in this activity. I therefore expressly request that I and/or my child be able to voluntarily participate in this activity. I understand and acknowledge that I waive and forever release and discharge the Camp Fire USA San Diego & Imperial Counties Council and its officers, employees, agents, and volunteers from all liability claims, losses, costs, or expenses arising from, or attributable to, the activity identified above. In addition, I further agree to defend, indemnify, and hold harmless CFSDI from and against any loss, judgment, fine, penalty, fees, or costs (including third parties’ or CFSDI’s own attorneys’ fees and costs whether or not a suit is brought) arising from any allegation or claim for injuries, damages, or losses of any kind resulting from me and/or my child’s participation in the Reach-Out Challenge Course. To the best of my knowledge, I do not, nor does my child, have any physical condition that would interfere with my/his/her ability to participate in or attend this activity or would endanger my/his/her health or any other member’s health. I grant Camp Fire USA the right to use, reproduce, assign and/or distribute photographs, films, videotapes, and sound recordings of me and/or my child for use in materials they may create. Should I or my child require medical treatment while participating in this activity, I hereby give Camp Fire USA San Diego & Imperial Counties Council permission to use its judgment in obtaining medical service for me or my child, and I give permission to the physician selected by Camp Fire USA San Diego & Imperial Counties Council to render medical treatment deemed necessary and appropriate by the physician. I understand that Camp Fire USA San Diego & Imperial Counties Council has no insurance covering any medical or hospital costs that might be incurred by me and/or my child and, therefore, any cost incurred for such treatment shall be my sole responsibility.
I have read completely and agree with this release form, as indicated by my signature below
Parent/Legal Guardian Signature:
Date:
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Camp Cahito Participant Agreement
and Release
Participation Agreement: We (child and parent/legal guardian) wish the child who signs below to participate in the camping program sponsored by Camp Fire USA San Diego & Imperial Counties Council. We recognize there may be risk of injury during such participation and certain dangers and accidents may occur. We further agree that each child participating in the program must follow safety instructions, remain in areas designated by staff, and refrain from behavior that is harmful to him/her or others. Failure to do so will be cause for the child’s dismissal from the program without refund. In consideration of the benefits to be received as the result of my child’s participation in the program, the receipt and sufficiency of which I (parent/legal guardian) hereby acknowledge, I hereby release, acquit, and forever discharge Camp Fire USA San Diego & Imperial Counties Council and officers, directors, trustees, employees, agents, and insurers of each of them, from all claims, responsibility of liability of whatever kinds and nature, whether arising from negligence, breach of contract or otherwise, on account of or arising from any injury or damage which may be sustained by my child as a result of my child’s participation in the program. I agree to defend and indemnify the Camp Fire USA San Diego & Imperial Counties Council and other officers, directors, trustees, employees, agents, and insurers of each of them against any and all manner of actions, claims, demands, damages, liabilities, or expenses of every kind and nature which may be incurred or arise by reason of my child’s participation in the program, including but not limited to any injuries my child may cause to other participants. I give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization for my child as named above. I agree to be responsible for any expenses that may be incurred in providing emergency medical or surgical treatment to my child.  My child has my permission to participate in all camp activities and to receive information regarding Camp Fire USA. I understand that in order to provide a safe and cooperative group experience, my child may be dismissed from the program without refund for reasons including behavior, illness or injury, or homesickness. Still and moving pictures of my child, and his/her name and voice may be used for publicity purposes.
Signature of Parent/Legal Guardian:
Date:
 
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Camp Cahito Program Selection
Please check each session you are registering for. One registration per camper.

Little Stars Camp

Camp Name

Dates

Amount
June 30th –July 3rd $100
July 7th – 11th $125
July 14th – 18th $125
July 21st – 25th $125
July 28th – August 1st $125
August 4th – 8th $125

Starflight Camp

Camp Name

Dates

Amount
June 23rd – 27th $155
June 30th – July 3rd $145
July 7th – 11th $155
July 14th – 18th $155
July 21st – 25th $155
July 28th – August 1st $155
August 4th – 8th $155
August 11th – 15th $155
 

Adventure Camp

Camp Name

Dates

Amount
June 23rd – 27th $165
June 30th – July 3rd $155
July 7th – 11th $165
July 14th – 18th $165
July 21st – 25th $165
July 28th – August 1st $175
August 4th – 8th $165
August 11th – 15th $165

Discovery Camp

Camp Name

Dates

Amount
July 28th – August 8th $330
Please note if you are interested in our Teen Volunteer Programs, the DASH and Junior Counselor Position, there is a separate packet. Please call Rochelle at the main office (619) 291-8985 to request the Teen Leadership Registration Packet for Summer 2008.

Extended Hours Selections
Extended hours are available for Starflight, Adventure and Discovery Campers. Please check the options you need below. Please not that if you do not sign up for extended hours but your camper is on camp between before 8:30am or after 4pm you will be billed. Campers will be charged $15.00 for every 15 minutes they are here after 5:30pm.
AM 7:30—9:00 $7.50 /day
PM 3:30—5:30 $10.00/day
Both AM/PM $16/day
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Starflight Camp
All Stars - June 23rd – 27th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Come and Get it - June 30th – July 3rd
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Otihac July 7th – 11th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
A Jungle Out There July 14th – 18th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Superhero Training July 21st – 25th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Wonders of Nature July 28th – August 1st
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Pirates of the Cahito August 4th – 8th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Final Fling August 11th – 15th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  

Adventure Camp
Camper vs. Wild June 23rd – 27th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Come and Get it June 30th – July 3rd
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Camp Chemistry July 7th – 11th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Green Week July 14th – 18th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Outside the Box July 21st – 25thh
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Wonders of Nature July 28th – August 1st
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Survivor August 4th – 8th
Mon.
Tues.
 		Wed.
Thurs.
 		Fri.
  
Final Fling August 11th – 15th