Adult Walker Application - Potawatomi Cub Scout Day Camp
June 24-27, 2008
Instructions and information
Each pack sending scouts to camp MUST provide 2 adults to walk with the wolves/bears AND 2 adults to walk with the Webelos EACH DAY. Adults may take a.m. and p.m. shifts by checking into camp at the Camp Directors office. Adults may purchase a camp T-shirt by ordering an additional shirt on the scout application form. Upon arrival at camp, walkers will assist their scouts in locating the area for the groups the scouts have been assigned to. Maps, schedules, and identification will be provided to walkers at opening ceremony. A daily walker briefing will take place during opening flag.
Name ____________________________________________________________ Pack # __________ Age _______
Address/City/State/Zip __________________________________________________________________________
Home Phone ___________________ Cell Phone ___________________ Email _____________________________
Have you served as an adult walker previously? _____________
Would you be interested in helping at a station as a staff member? __________ Station preferred _______________
Days attending camp: (circle) Tues am Tues. p.m. Wed. a.m. Wed. p.m. Thurs. a.m. Thurs. p.m. Fri. am Fri. p.m.
Pixie campers attending with you ($10 per day/per pixie): _______________________________________________
Scout you will be walking with: _______________________________ (circle rank in the fall) Wolf/Bear Webelos
Emergency Information
In case of emergency notify _________________________ relationship __________ Telephone _______________
Other contact _________________________________________________________ Telephone _______________
Personal Insurance Company _____________________________________________Policy # _________________
Family Doctor ________________________________________________________Telephone ________________
Health History
Check all items that apply, past or present. 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 _____ Hearing impairment _____ Other ________________
List any medications you 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 I 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 understand that photographic images taken may be used to promote Day Camp.
Signature: ____________________________________ Date: _______________
Comments: If you have attended camp as a walker previously, and would like to make a comment or suggestion prior to this year’s camp, please use this space to do so.