Cub Scout Application - Potawatomi Cub Scout Day Camp
Camp Topenebee, Michigan City June 24-27, 2008
Pixie camp is available for staff and those parents who are walking with Scouts yet have smaller sons, or daughters, to care for. The cost is $10.00 per day for each pixie, the child must be potty trained, and the parent must remain on the premises during the time the child is in camp. Pixie camp is supervised by qualified volunteers with the help of teenage assistants. There are crafts, activities, and snacks provided throughout the day for your pixie’s enjoyment. A camp t-shirt may be purchased for your pixie by ordering an additional shirt on the scout’s application.
Pixie’s Name _________________________________________ Nickname ____________________
Parent’s Name ___________________________________________ Pack # of brother _____________________
Address/City/State/Zip ____________________________________________________________________________
Home Phone ___________________ Cell Phone ___________________ Parent’s Email________________________
Age _____Days attending camp: (circle) Tues a.m Tues. p.m. Wed. a.m. Wed. p.m. Thurs. a.m. Thurs. p.m. Fri. p.m.
Emergency Information
In case of emergency notify _____________________ relationship _______ Telephone ______________Cell_________
Other contact _________________________________________________________ Telephone ___________________
Personal Insurance Company _____________________________________________Policy # _____________________
Family Doctor ________________________________________________________Telephone ____________________
This pixie may leave camp with the following people: _____________________________________________________
Health History
Check all items that apply, past or present to the Pixies health history. Explain any checked answers using the back of this form if necessary.
Allergies: Food, medications, bee stings, insects, or plants _______ Explain: _______________________________
High Blood Pressure _____ Asthma _____ Convulsions/seizures _____ Heart trouble _____
Cancer/leukemia _____ Diabetes _____ Fainting Spells _____ Hemophilia _____
Kidney disease _____ ADHD _____ Hearing impairment _____ Other ________________
List any medications the pixie will be taking at camp: _____________________________________________________
List any physical or behavioral conditions that may affect or limit full participation __________________________
List any special needs or equipment used such as a wheel chair, crutches, glasses, contacts ____________________
Authorization
This health history is correct so far as I know and my Scout will be able to engage in all prescribed activities, except as noted by me. In the event of illness in the course of such activity, I request that measures be instituted without delay as the judgment of medical personnel dictates. I agree that images of this youth may be used to promote day camp.
Parent Signature: _______________________________ Date:______________
** PIXIE CAMP FEES WILL BE COLLECTED AT CAMP ($10.00/Day per child)
Comments: If this child has attended camp as a pixie previously and you have a comment or suggestion, or, you have something you would like us to know about this child, please use this space to offer your remarks.