For more info go to: www.hiawathacamp.org

or call (316) 838-7871 today.

Summer Day Camp

2016

Early Explorer Day Camp

Entering Grades: 1 - 2 7:00am - 5:30pm Daily

Cost: $120/wk. Max. 25

Outdoor Adventure Day Camp

Entering Grades: 5 - 6 7:00am - 5:30pm Daily

Cost: $120/wk. Max. 35

Jr. High Challenge Day Camp

Entering Grades: 7 - 8 7:00am - 5:30pm Daily

Cost: $120/wk. Max. 25

The perfect end to an amazing summer! This is what summer camp is all about…You and your friends having fun in the sun! High flying action, team building challenges, late night camp fire under the stars,

crazy camp games and memories to last a lifetime! Overnight camp will encourage you with meaningful relationships and thrill you with riveting adventure. Don’t miss it!

Day Camp Week 1: 5/31 - 6/3 (Tue - Fri) Time Machine – Blast off into another time dimension as we explore ancient Egypt, travel the Oregon Trail, Sock Hop into the 1950’s, and wonder what life would be like long ago in a galaxy far, far away….

Day Camp Week 2: 6/6 - 6/10 (Mon - Fri) Amazing Race – Grab your passport as we embark on a virtual international excursion! Fascinating tour guides will lead you into diverse cultures and unexpected adventures. Get Ready. Get set. Go!

Day Camp Week 3: 6/13 - 6/17 (Mon - Fri) Top Chef – Learn kitchen safety and basic cooking techniques while creating a variety of culinary delights. Teams will be challenged in creativity, presentation, taste, marketing, & more. Bon Appétit!

Day Camp Week 4: 6/20 - 6/24 (Mon - Fri) Olympics – The summer Olympics are here! Come ready to compete in classic Olympic Games and some not-so-traditional events. Go for the Gold!

Day Camp Week 5: 6/27 - 7/1 (Mon - Fri) Spy Academy – Here is your mission should you choose to accept it. Come experience top secret spy training and activities to enable you to solve the camp mystery. This message will self-destruct in 30 seconds...

Day Camp Week 6: 7/5 - 7/8 (Tue - Fri) Holiday Hoopla – Deck the halls for a holiday good time! Come join in the fun as we celebrate a different holiday each day this week.

Day Camp Week 7: 7/11 - 7/15 (Mon - Fri) American Turtle Ninja Warrior – Join Leonardo, Donatello, Raphael and Michelangelo in this diverse week of reptiles, renaissance artists, and rousing team building battles..

Day Camp Week 8: 7/18 - 7/22 (Mon - Fri) LIFE – Step into a LIFE size board game. Experience challenges, accomplishments, and life milestones to earn your wages. Will you be able to retire in style by the end of the week?

Day Camp Week 9: 7/25 - 7/29 (Mon - Fri) Bon Voyage – All aboard the Hiawatha Cruise line. Surrounded on all sides by water this week, enjoy the sun and ship activities. Create a tropical paradise for all to visit at the port-of-call. Wear lots of sunscreen!

Day Camp Week 10: 8/1 - 8/5 (Mon - Fri) S’mores and Some More – (1st - 4th Grade Only) Want to go camping but not ready to stay overnight? Come along for shelter building, campfire cooking, nature hiking and s’more! 5th - 8th Graders, Check out our overnight camps!

Pre-Teen Overnight Camp

PT-ON Aug. 1 - Aug. 5 4:00pm Mon - 10:00am Fri

Pre-Teen Overnight Camp (Grades 5-6) Cost: $189

Jr. High Overnight Camp

JH-ON Aug. 1 - Aug. 5 4:00pm Mon - 10:00am Fri

Jr. High Venture Trek (Grades 7-9) Cost: $189

Woodland Voyager Day Camp

Entering Grades: 3 - 4 7:00am - 5:30pm Daily

Cost: $120/wk. Max. 35

Our young friends will explore the great outdoors in a safe, high energy, loving environment. This state licensed Day Camp program is a blessing to children and youth wanting a summer camp experience and to parents looking for

quality “out-of-the-box” summer child care.

For our two youngest age groups, our camp program includes free daily swim lessons, theme based activities, nature encounters, group games, arts & crafts and more! Third and Fourth Graders will add archery, the climbing

tower with zip lines and activity choices wherein each camper will choose activities and experiential learning opportunities which interest them most.

Our two older age groups are even more adventurous featuring our climbing tower with zip lines plus team building and problem solving initiatives. Every day will be a new encounter with unique, theme based activities and

enhanced program choices and experiential opportunities!

Regardless of their age, your camper will go home each day dirty, tired and begging for more!

Hiawatha Day Camp is approved for DCF- child care assistance!

“Camp Hiawatha is more fun

than my mom can handle.”

- Zach, 3rd grade camper

“Your exceptional staff showed great love, care,

compassion & understanding for our grandson.

Thank you!” - L.K.

“Hooray, Camp Hiawatha! My son just finished his first week at your camp and he is begging me to

sign him up for the whole summer! Keep up the

good work.” - M.Z.

“You treated my kids like they were highly valued,

important, wanted, special and mostly, that they were worth it!

I think you’ve got the cream of the crop in the counselors

you’ve chosen.” - L.H.

1601 W. 51st St. N.

Wichita, KS 67204

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“Thank you for all you did for my kids this summer! I appreciate all the fun

activities you planned and the care they received while

at Camp Hiawatha. We will definitely be back

next summer!” - D.M.

NOTICE: USD 259 neither sponsors nor endorses the organization or activity represented in this document and the content or views expressed herein are solely that of the organization shown. USD 259 permits the distribution of material such as this on a non-discriminatory basis regarding matters of potential interest to students and parents.

Hiawatha Camp & Retreat Center is a ministry of

The Salvation Army - Wichita City Command

350 N. Market St. Wichita, KS 67202

Will you consider giving the gift of camp to a child in need?

——- Yes, please use my enclosed donation of $______ as a partial camp scholarship. ——- Yes, I have enclosed $120 to scholarship one child, for a week of camp. ——- Yes, I have enclosed $240 to scholarship two children, for a week of camp. ——- Yes, I have enclosed $480 to scholarship four children, for a week of camp. ——- Yes, I have enclosed $______ to scholarship many children, for a week of camp.

Please mail your donation to:

The Salvation Army

350 N. Market St.

Wichita, KS 67202 designate Camp Hiawatha scholarships

Thank you!...for investing in the lives of local children.

Camp Hiawatha Registration Form 2016

CAMPER’S INFORMATION

First Name: __________________________________________ Last Name: _______________________________________________________

Mailing Address: __________________________________________ City: _________________________ State: ___________ Zip: __________

Home Phone: (______) ___________________________ E-mail Address: __________________________________________________________

Birth date: _______/________/__________ Male: ______ Female: ______ School Grade for Fall 2016: _______________________

Camper attends school at : _______________________________________________________________________ T-Shirt Size: (circle one)

Camper attends church at: _______________________________________________________________________ Child: 6/8 10/12 14/16 (Church Name / City)

Referred to camp by: ______School Flyer ______friend (name of friend________________________________) Adult: S M L XL

______I am a returning camper ______Mail Flyer ______Other (please specify________________________________________)

EMERGENCY INFORMATION

Mother or Legal Guardian’s Name: ___________________________________Employer: ________________________________

Mailing Address: __________________________________ City: ___________________ State: _________ Zip: ______________

Telephone | Home: (_____) ____________________ Work: (_____) ____________________ Cell: (_____) ___________________

Father or Legal Guardian’s Name: ___________________________________Employer: ________________________________

Mailing Address: __________________________________ City: ___________________ State: _________ Zip: ______________

Telephone | Home: (_____) ____________________ Work: (_____) ____________________ Cell: (_____) ___________________

Other Emergency Contact:_____________________________________________Relationship to camper: ___________________

Mailing Address: __________________________________ City: ___________________ State: _________ Zip: ______________

Telephone | Home: (_____) ____________________ Work: (_____) ____________________ Cell: (_____) ___________________

CHOOSE CAMP DATES

1601 W. 51st St. N.

Wichita, KS 67204

(316) 838-7871

Mark an “X” in the boxes of the weeks your child will attend

I understand that Camp Hiawatha is a Christian camp and lessons will be taught from The Bible. I understand that if my child does not participate

in the camp program, adhere to camp policies, or is involved in misconduct, he/she may be sent home without refund.

________________________________________________________________________________________________________________________ _____________________________________________________

Signature of Parent / Legal Guardian Date

Cost:

$120 for

each week

1

5/31-6/3

*closed

5/30

2

6/6-6/10

3

6/13-6/17

4

6/20-6/24

5

6/27-7/1

6

7/5-7/8

*closed

7/4

7

7/11-7/15

8

7/18-7/22

9

7/25-7/29

10

8/1-8/5

*Day Camp is

only for

1-4 grades

Day Camp

Overnight

Camp

5-6 grade

Overnight

Camp JH

Anticipated days & hours of

Day Camp attendance.

Monday ____ to ____

Tuesday ____ to ____

Wednesday ____ to ____

Thursday ____ to ____

Friday ____ to ____

*Please note hours of operation are

7 am to 5:30 pm.

YES NO I give permission for photos of my child to be

used for promotional & programming purposes. If not, then please attach

photo of your child.

YES NO I give permission for my child to participate in

swimming activities supervised by certified lifeguards.

YES NO I give permission for my child to participate in Camp Hiawatha’s

climbing wall and zip line with proper certified staff supervision. Safety equipment will be worn.

YES NO I give permission for my child to participate in archery with proper certified

staff supervision.

2016 CAMP REGISTRATION INSTRUCTIONS & POLICIES

DAY CAMP INSTRUCTIONS ONLY

Complete registration form, health forms, and emergency authorization.

School grades listed refer to the grade for the fall of 2016.

Registration form MUST be signed by the parent or legal guardian.

Please make a copy for your personal reference.

Plan to attend the parent meeting for information regarding camp policies and what to bring to camp.

A Deposit equal to one week’s camp is required to hold your child’s reservation. These funds will be applied to

your last week of day camp.

Each week’s payment is due no later than the Monday prior to the week attended.

Please note the dates for which you have registered. A two week notice is required to change dates at no cost to you.

There will be no refund for no-shows.

Register early! There may be a limited number of spaces available this year.

REGISTRATION INSTRUCTIONS FOR ALL OTHER CAMPS

Fill out the forms completely with accurate information. Incomplete information will slow down the registration

process. Payment for overnight camps needs to be made in full at the time of registration.

School grades listed refer to the grade for the fall of 2016. Please select camps for the appropriate grade level.

Registration form MUST be signed by the parent or legal guardian.

A confirmation letter will be mailed after the registration is processed. This will include

information about what to bring to camp, as well as arrival and departure times.

After completing the registration and health forms, make a copy for future reference.

Registrations will not be made over the phone.

CANCELLED REGISTRATIONS & REQUESTS TO CHANGE CAMPS:

Full refund: 15 days or more before camp’s start date.

50% refund: 14 days or less before camp’s start date.

No refund for changes or cancellations made 7 days or less before camp’s start date.

Full refund given if a camp is full or cancelled.

HELPFUL REMINDERS:

Register early! Some camps may fill up quickly.

Campers/parents are responsible for transportation to and from camp.

Any questions? Contact Kim Herrman

(316) 838-7871

camp_hiawatha@usc.salvationarmy.org

PAYMENT INSTRUCTIONS

Send payment along with necessary forms.

Make checks payable to CAMP HIAWATHA.

Mail to:

1601 W. 51st Street N.

Wichita, KS 67204

Mandatory Parent Meetin

g

Please plan to attend.

May 26, 7 pm

OR

May 28, 9 am

Children are encouraged

to attend

CCL. 358 Kansas Department of Health and Environment Rev. 1/2014 Bureau of Family Health Child Care Licensing Program

1000 SW Jackson, Suite 200 Topeka, KS 66612-1274

Phone: (785) 296-1270 Fax (785) 296-0803 Website: www.kdheks.gov/kidsnet

HEALTH HISTORY FOR CHILDREN AND YOUTH ATTENDING SCHOOL AGE PROGRAMS As required by K.A.R. 28-4-590(d) (1), each operator shall obtain a health history for each child or youth, on a form supplied by the department or approved by the secretary. Each health history is to be maintained in the child’s or youth’s file on the premises. As required by K.A.R. 28-4-590(d)(2), each operator shall require that each child or youth attending the program has current immunizations as specified in K.A.R. 28-1-20 or has an exemption for religious or medical reasons. Complete one form for each child or youth attending the School Age Program. First and Last Name of the Child or Youth

Gender (M or F)

Date of Birth (MM/DD/YYYY)

First day at this program: (MM/DD/YYYY)

First and Last Name of the Child’s or Youth’s Mother or Guardian

Mother/Guardian’s Home Street Address

City Zip Code Home Phone #

( ) Mother/Guardian’s Work Place Name & Street Address

City Zip Code Work Phone #

( ) First and Last Name of the Child’s or Youth’s Father or Guardian

Father/Guardian’s Home Street Address City Zip Code Home Phone #

( ) Father/Guardian’s Work Place Name & Street Address

City Zip Code Work Phone #

( ) Names and ages of other children in the Child or Youth’s Family (Attach additional page if needed.)

Person(s) authorized to pick up the Child or Youth in case of emergency. Include first and last name and Street Address. Attach additional page if needed. 1.

City Zip Code Phone Number (during program hours):

2.

3.

First and Last Name of Physician & Street Address City Zip Code Phone Number

( ) Name of Hospital Preference in case of emergency.

Yes No N/A Complete the following information about medications for this child or youth.

Will this child or youth need to take any nonprescription or prescription medication during their time at the program?

If yes above, is there signed permission on file?

Circle any of the following conditions or difficulties that affect this child or youth.

Allergies Frequent sore throats/ colds Ear Infections or Aches Heart or Lung Conditions

Skin Problems Asthma Headaches Diabetes

Vision Speech/Communication Hearing Emotion/Behavior

Other: Please describe.

If you circled any of the above conditions, please provide additional information that will help the staff members meet the child’s or youth’s needs while attending the program. (Attach additional page, if needed.)

Provide additional information about your child or youth that might affect him/her while at the School Age Program including any special needs, restrictions to activities, major changes at home or special instructions. (Attach additional page, if needed.

Complete the following information about this child’s or youth’s immunization status. Yes No

Did this child or youth attend a public or accredited non-public school in Kansas, Missouri or Oklahoma the previous year?

If yes, are this child’s or youth’s immunizations current?

If yes to both of these questions, you do NOT need to complete the immunization history below. If no to either of the above questions, you must complete the immunization history below for this child or youth or attach a copy of the child’s or youth’s immunization history.

Please give dates in the space below for ALL immunization series completed by this child or youth. Record MM/DD/YYYY.

1 2 3 4 5

DPT, DT*, TD (*DT only if child is allergic to DTP) / / / / / / / / / /

POLIO / / / / / / / /

MMR / / / /

Single

Dose

Only

RUBEOLA (MEASLES) / / / /

MUMPS / / / /

RUBELLA (GERMAN MEASLES) / / / /

HIB (Hemophilus Influ. B) *RECOMMENDED / / / / / / / /

HBV (Hepatitis B Vaccine) *RECOMMENDED / / / / / /

VAR (Varicella-Chicken Pox) *RECOMMENDED / /

Print the First and Last Name of the Person Completing this Health History form

Relationship to the Child/Youth

Date Completed

If the Health History form was completed by a person other than a Parent/Guardian, who provided you with this information?

What is that person’s relationship to the child/youth?

I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this form is true and correct.

Signature of person completing this form Date Signed

CCL 010 Kansas Department of Health and Environment Rev. 6/2015 Bureau of Family Health 1000 SW Jackson, Suite 200 Topeka, KS 66612-1274 Child Care Program: (785) 296 -1270 Fax: (785) 296 -0803 Website: www.kdheks.gov/kidsnet

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4-582(e)(2).

Name of facility exactly as stated on the license.

License #

I hereby authorize _________________________________________________________ (Name of individual/staff member) and/or ____________________________________________________ (Name of individual/staff member) who is (are) representative(s) of the above named facility to give consent for any and all necessary emergency medical care for my child or youth _____________________ ___________________________________________ (First and Last Name of Child or Youth) while said child or youth is in said facility’s custody between the dates of ___________________________ and ____________________________. MM/DD/YYYY MM/DD/YYYY

Signature of Parent or Guardian Date Signed

Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic. Date Signed

Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.

State of Kansas County of ________________________

Signed or attested before me on ____________________ by______________________________________________.

MM/DD/YYYY Name of Person

(Seal, if any.)

_______________________________________________

Signature of notarial officer

______________________________________________

Title (and Rank)

My appointment expires: __________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency:

Is child covered by health insurance? Yes No

If yes, complete the following:

Health Insurance Policy Name _________________________________________ Policy Number ______________________

Medical Assistance Program ____________________________________________ Card Number________________________

Military Medical Care I.D. Number ___________________________________________________________________________

If known, date of last Tetanus inoculation: __________________________________

THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST ALSO BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THE FACILITY.