SS Office Only:
Denver Fire Department2021 Young Adult Career Exploration Camp ApplicationAll sides of this form must be COMPLETED AND SIGNED before the child may attend.Select one:Camp Dates: July 26 - 28 (Co-Ed) ________________________ Camp Dates: July 28 - 30 (Ladies Only) __________________PERSONAL INFORMATION1st Child's Full Name (first, middle, last)T-Shirt SizeYouth S M L XL Adult S M L XL FemaleMaleAge:Birth Date:2nd Child's Full Name (first, middle, last)T-Shirt SizeYouth S M L XL Adult S M L XLFemaleMaleAge:Birth Date:3rd Child's Full Name (first, middle, last)T-Shirt SizeYouth S M L XL Adult S M L XLFemaleMaleAge:Birth Date:PRIMARY EMERGENCY CONTACT INFORMATIONThese individuals are considered authorized adults and can pick up the above child(ren) from the program.Guardian Information, Relationship:Order of Contact (Circle One): 1 - 2 - 3 - 4 - 5Name:Email Address:Address:City:State:Zip:Home Phone:Cell Phone: Work Phone:Employer: Work Address: City/State:ZipGuardian Information, Relationship:Order of Contact (Circle One): 1 - 2 - 3 - 4 - 5Name:Email Address:Address:City:State:Zip:Home Phone:Cell Phone: Work Phone:Employer: Work Address: City/State:ZipALTERNATE EMERGENCY CONTACT PERSONS - You MUST complete this section.My child(ren) may also be picked up by the following authorized adults other than his/her parents.Name:Relationship:Order of Contact (Circle One): 1 - 2 - 3 - 4 - 5Home Number:Work Number:Cell/Pager:Address:City/State:Zip:Name:Relationship:Order of Contact (Circle One): 1 - 2 - 3 - 4 - 5Home Number:Work Number:Cell/Pager:Address:City/State:Zip:Name:Relationship:Order of Contact (Circle One): 1 - 2 - 3 - 4 - 5Home Number:Work Number:Cell/Pager:Address:City/State:Zip:GENERAL INFORMATION I understand the Drop Off/Pick-up procedure.___________________Parent/Guardian SignatureDROP OFF / PICK-UP PROCEDUREI understand that the City & County of Denver is not responsible for children that walk to and from the DFD Career Exploration program site until/after they are signed in/out either by themselves or by a parent, guardian, or authorized alternate. As a parent and/or guardian of the child(ren), I am responsible for my child(ren) before they sign in for the program and after they sign out.I authorize my child(ren) to sign into/out of the DFD Career Exploration program and walk home from the recreation program by themselves.YES _______ (Initial) NO ______ (Initial)I authorize my child(ren) to sign into the DFD Career Exploration program and should always be picked up by a parent/guardian or authorized adult who will sign them out of the recreation program.YES _______ (Initial) NO ______ (Initial)My child attends this school ___________________________________________ ____________________________________________ (name of school) (address)MANDATORY ORIENTATION I understand that once selected to attend, a parent/guardian must attend a mandatory orientation meeting on either: Thursday, July 15th or Friday, July 16th, prior to their child(ren) attending camp. YES _______ (Initial) NO ______ (Initial)I understand that the orientation will take place at the Rocky Mountain Fire Academy, 5440 Roslyn Building #5, Denver, CO 80216, starting at 6:30 pm and ending around 8pm.YES _______ (Initial) NO ______ (Initial)I will be attending the mandatory orientation on: Thursday, July 15th ________________ Friday, July 16th ________________ (I have previously attended on __________) (All Camp Participants are welcome to attend) DateLATE PICK-UP PROCEDUREIt is important that you pick-up your child(ren) by closing time of the program. The Fire Department Career Exploration Camp will end at 4pm each day. If your child(ren) is/are not picked up on time, staff will call all contact numbers on the Emergency Phone Number List. Calls will be made 15 and 30 minutes after program dismissal. 1/2 hour after program dismissal we will notify the police to pick up your child(ren). They will be transported to the nearest Denver District Police Station where continued attempts to contact family will occur. We will make every effort to contact someone at the emergency numbers you have provided. Please remember to notify staff of all emergency phone number changes.Parent/Guardian Signature ___________________________________________________________ Date ______________________________RELEASES ON SITE SPECIAL EVENT PERMISSION: My child(ren) has my permission to attend any on site special events with the program including challenge courses and various enrichment activities. I understand that advanced notice of each special event will be given at the mandatory Parent Orientation.YES______(Initial)NO_____(Initial)SUNSCREEN RELEASE: I give permission for the DFD Career Exploration staff to assist my child(ren) with applying sunscreen to bare surfaces including the face, and tops of ears, and may assist in applying sunscreen in spray form to bare shoulders, arms, legs and feet 15-30 minutes before outdoor activities. Sunscreen will not be applied to any broken skin or if a skin reaction has been observed. Any skin reaction observed by staff will be reported promptly to the parent/guardian. It is the parent/guardian’s responsibility to provide sunscreen with a minimum SPF of 15. YES______(Initial)NO_____(Initial)PHOTO RELEASE: I hereby give full consent to Denver Fire Department to copyright or publish any photographs/videos taken by them in which my child(ren) appears. I agree they may use these photographs/videos for public display and/or publication. YES______(Initial)NO_____(Initial)PROGRAM PERMISSION RELEASE: In accordance with my decision to register my child for this DFD Career Exploration Program, I hereby acknowledge that I have read a copy of the program's General Information Flyer. I am also aware that the complete Policy and Procedure Manual is available at the mandatory orientation. I agree to abide by the policies outlined in both the General Information and the Policy and Procedure Manual. I further acknowledge that they are subject to change at the discretion of Program Administrators. I also acknowledge that I have read and signed all required sections of this application.YES______(Initial)NO_____(Initial)Parent/Guardian Signature for all releases listed above: ___________________________________________ Date ______________________MEDICAL RELEASEI do hereby authorize officials of the Denver FD Career Exploration program to contact directly the persons named on this application and do authorize the named physician or their associate to render such treatment as may be deemed necessary in an emergency for the health of the said child(ren). In the event that a parent/guardian or alternate persons named on this application cannot be reached, the Denver FD officials are hereby authorized to take whatever action is deemed necessary in their judgment for the health of aforesaid child(ren). I agree I am solely responsible for payment of all costs resulting from the tendering of medical and ambulance services.I understand the Medical Release policy.____________________Parent/Guardian Signature____________________DateMEDICAL HISTORY AND INFORMATION1st Child Name ________________________2nd Child Name ________________________3rd Child Name _________________________Please check any illnesses that your child has had:Chicken Pox ____ Measles ____ Rubella ____ Hay Fever ____Diabetes ____ Asthma ____Epilepsy ____ Mumps ____Poliomyelitis ____ Whooping Cough ____Rheumatic Fever _____ Please check any illnesses that your child has had:Chicken Pox ____ Measles ____ Rubella ____ Hay Fever ____Diabetes ____ Asthma ____Epilepsy ____ Mumps ____Poliomyelitis ____ Whooping Cough ____Rheumatic Fever _____ Please check any illnesses that your child has had:Chicken Pox ____ Measles ____ Rubella ____ Hay Fever ____Diabetes ____ Asthma ____Epilepsy ____ Mumps ____Poliomyelitis ____ Whooping Cough ____Rheumatic Fever _____ Surgery / Accidents / Chronic Health Problems:______________________________________________________________Surgery / Accidents / Chronic Health Problems:______________________________________________________________Surgery / Accidents / Chronic Health Problems:______________________________________________________________Describe any physical condition requiring special attention by our staff: ______________________________________________________________Describe any physical condition requiring special attention by our staff: ______________________________________________________________Describe any physical condition requiring special attention by our staff: ______________________________________________________________Check those allergies staff should be aware of:Food (type) ____________________________Insect Bites / Stings _____________________Penicillin ______________________________Other Drugs ___________________________Check those allergies staff should be aware of:Food (type) ____________________________Insect Bites / Stings _____________________Penicillin ______________________________Other Drugs ___________________________Check those allergies staff should be aware of:Food (type) ____________________________Insect Bites / Stings _____________________Penicillin ______________________________Other Drugs ___________________________Date of most recent examination of this child: ______________________________________Date of most recent examination of this child: ______________________________________Date of most recent examination of this child: ______________________________________ Does your child require any additional accommodations? (Please circle)? ?????? Yes? ??? No If Yes, please note accommodation below:PHYSICIAN / DENTIST / INSURANCE INFORMATIONYOU MUST MAINTAIN AND UPDATE ANNUALLY AN IMMUNIZATION HISTORY FOR YOUR CHILD(REN).INCLUDE A COPY OF CHILD'S IMMUNIZATION CARD WITH THIS APPLICATION.Physician / Health Care Professional:Telephone:Address/City/Zip:Does Not Have □Dentist:Telephone:Address/City/Zip:Does Not Have □Hospital of Choice:Telephone:Address/City/Zip:Does Not Have □Medical Insurance Co: Telephone:Does Not Have □Group Number: Policy Number:Any/all additional medical information not addressed above, please explain: ____________________________________________________________________________________________________________________________________________________1st Child's Ethnicity(Circle all that apply)2nd Child's Ethnicity(Circle all that apply)3rd Child's Ethnicity(Circle all that apply)Languages Spoken in the Home(Circle all that apply)Who Does the Child(ren) Live With(Circle all that apply)African AmericanAngloAsianLatinoNative AmericanOther: ________1. African AmericanAngloAsianLatinoNative AmericanOther: ________African AmericanAngloAsianLatinoNative AmericanOther: ________EnglishSpanishOther: _____________MotherFather StepmotherStepfatherGrandmotherGrandfatherOther RelativeNon RelativeMANDATORY DISCIPLINE POLICY & PROCEDUREPARTICIPANT DISCIPLINE POLICYOur staff uses positive methods of guidance that encourage independence and a sense of responsibility.? Redirection is one strategy our staff uses to guide the participant from inappropriate play to a more appropriate behavior.? Communication can include giving alternative choices to their behavior in an effort to assist the participant with problem solving. Physical punishment is never used.?Participants will not be subjected to physical or emotional harm or humiliation.? ?In order to make the Denver FD Career Exploration program a positive experience for all participants, we ask that all participants exhibit appropriate social behavior and observe the following three basic principles:?Keep yourself safe??? *??? Keep others safe??? *? ??Keep the materials and equipment safe?Appropriate Social Behavior: Participants will refrain from behavior that can be detrimental to themselves, the group, or our staff (i.e., hitting, kicking, self-abusing, refusal to stay with group, running, etc.).? If a participant’s behavior is deemed detrimental, a parent or guardian will be called and will be required to pick up the participant within the hour.? At the onset of inappropriate behavior, our staff will begin to follow the Participant Discipline Policy, which may result in the participant having to withdrawal from the program at the time of the third DISCIPLINE/INCIDENT REPORT.?When a participant does not display the behavior expectations for the program, the staff will engage in preventative strategies that may include: verbal prompting, setting limits and consequences, and maintaining open communication with the participant, parents/guardians, and other staff. If the participant does not respond to these preventative measures, the following discipline steps will be taken:?At the time of the first DISCIPLINE/INCIDENT REPORT, direct communication with the parent/guardian will occur.? When the participant is picked up, a conversation will be conducted with the participant, parents/guardians, and staff on-site to inform them of the participant’s behavior and involve them in a problem-solving strategy that is appropriate for the participant.At the time of the second DISCIPLINE/INCIDENT REPORT, the participant will be suspended from the program.? Direct communication with parents/guardians will occur, to ensure that they have knowledge of the imposed consequence.? Before the participant may return to the program, a meeting must be held to create a behavior plan. 3.? At the time of the third DISCIPLINE/INCIDENT REPORT, the participant will be withdrawn from the program. ?If at any time, a significant or major issue occurs, which endangers the participant, other participants, or staff, immediate withdrawal from the program may ensue. ?If at any time a participant knowingly makes a false accusation of child abuse against a DFD Career Exploration Camp employee, the participant shall be immediately suspended from?the program, with a follow-up parent meeting required before participant may return to program.?Depending on the severity, this may also result in a withdrawal from program.?Additionally, if at any time a participant leaves the immediate program area in anger or for any other reason, a reasonable attempt will be made to stop him/her.? If they continue to flee, 911 will be called and the participant may be reported as a runaway.? Parents will then be contacted.?This behavior will result in a DISCIPLINE/INCIDENT REPORT, and the appropriate consequences will occur._________________________________________________________________________ ___________________________1st Child's Signature Date_________________________________________________________________________ ___________________________2nd Child's Signature Date_________________________________________________________________________ ___________________________3rd Child's Signature Date_________________________________________________________________________ ___________________________Parent/Guardian's Signature Date ................
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