Cub Scout Application - Potawatomi Cub Scout Day Camp

Camp Topenebee, Michigan City  June 24-27, 2008

Name ___________________________________________ Nickname ____________________Pack # __________

Parent’s Name ___________________________________________ Will a parent be serving as a walker?  Yes   No

Address/City/State/Zip ____________________________________________________________________________

Home Phone ___________________ Cell Phone ___________________ Parent’s Email________________________

Age as of June 13 _____ Grade in school Fall 08 _____ Scout Rank in Fall 08:  Tiger/Partner    Wolves    Bears    Webelos

Please Note: TIGER CUBS MAY ONLY ATTEND CAMP WITH AN ADULT PARTNER PRESENT! (Tiger Cubs are first graders or 7 yrs old) If Tiger Cub, name of adult partner attending camp with scout ___________________________________________________________

Emergency Information                                                                                                        

In case of emergency notify _____________________ relationship _______ Telephone ______________Cell_____________

Other contact _________________________________________________________ Telephone _______________________

Personal Insurance Company _____________________________________________Policy # _________________________

Family Doctor ________________________________________________________Telephone ________________________

This scout may leave camp with the following people: _________________________________________________________

Health History

Check all items that apply, past or present to the Scouts 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 scout 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:______________

Fees                                           Before May 16                       May 17 –May 30          May 31 –Opening day                     

               $45.00                                   $50.00                            $60.00 ***

__________ + $1.50 for each additional patch desired

__________ + $7.00 for each additional t-shirt desired

__________ Total fees attached

Please indicate the t-shirt sizes you are requesting on the table to the right! T-shirt sizes cannot be guaranteed. The camp reserves the right to substitute a larger size for a smaller one.

** PIXIE CAMP FEES WILL BE COLLECTED AT CAMP ($10.00/Day per child)

***there is no guarantee your Cub will receive a t-shirt

Please forward all forms to your Pack’s Camping Coordinator.  He or she will submit all forms for your pack at the same time.  If your pack does not have a camping chairman, you may submit your forms and payment to

LaSalle Council, 1340 South Bend Avenue. South Bend, IN, 46617

For program information contact:  Bonnie Hodge at 269-465-5428