1. Healthcare

CAMP VALOR 2015
August 3-7
Utah Hemophilia Foundation
772 East 3300 South, Suite 210
Salt Lake City, UT 84106
(801) 484-0325/ Toll Free 877-463-6893
www.hemophiliautah.org
Camp Valor Teen Program
Changes have been made to this program.
Please read the following before applying
Due to limited space in the Camp Valor Teen Program, not all
applicants will be accepted. The following is required to be
considered for participation:
Priority will be given to teens with a bleeding disorder or
who have been diagnosed as a carrier.
Must be between the ages of 14 and 16.
Have the maturity to relate to peers and adults in a positive
manner.
Have the ability to communicate and work with other teens
and adult volunteers.
Maintain a positive and cooperative attitude with all
members of the Teen Program and Camp Valor staff.
Be physically able to participate in activities on a daily basis
and other group related experiences.
*Teen applications will not be accepted after July 6, 2015
No Exceptions!
*Financial assistance is available if the registration fee is hardship. Please
fill out and submit “Request for Financial Assistance” form, available on the
UHF website.
Camp Valor Teen Program
August 3—7, 2015
Application Form
TEEN APPLICATIONS WILL NOT BE ACCEPTED AFTER JULY 6, 2015.
_________________________________________________________________________
Teen’s Last Name
First Name
Preferred Name/Nickname
________________________________________________________________________
Address
City
State
Zip
________________________________________________________________________
Home Phone Number
Birth Date (MM/DD/YYYY)
Male/Female
________________________________________________________________________
Parent /Guardian Name
Parent Cell Phone Number
Teen Cell Phone Number
________________________________________________________________________
Parent/Guardian Email Address
Teen Email Address
Bleeding Disorder Status (check one):
(Priority given to those with bleeding disorders and diagnosed as a carrier)
TYPE:
Payment Enclosed:
$70 reduced registration fee if received at the UHF office by June 5, 2015.
$80 registration fee if received between June 6 and June 22, 2015.
$90 registration fee if received between June 23 and July 6, 2015
Paid online with my Mastercard, Visa, Discover or AmEx, through Firstgiving.com
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Go to www.firstgiving.com/uhf
Click on the green Donate button on the right side of the screen
Enter requested credit card information—use fee scale as listed above
Enter “Camp Valor Registration” in the Comments section
‘Request for Financial Assistance’ form.
Make checks payable to the UHF and mail with registration form:
Utah Hemophilia Foundation
772 East 3300 South, Suite 210, Salt Lake City, UT 84106
Phone: 801-484-0325 /Toll Free: 877-463-6893
Fax: 801-746-2488
Please have the teen applicant answer the following questions completely, using
additional pages if necessary.
Please give an example of how you support the Utah Hemophilia Foundation in accomplishing
its mission.
What are the qualities or characteristics you have that would enhance the Teen Camp
Program?
If you had the opportunity to be in the Teen program last year at Camp Valor, please tell us
about some of your favorite experiences.
Please list the names and telephone numbers of three individuals, to whom you are not related
and do not work at the UHF, that we may call for a reference:
___________________________________________________________________________
Name
Phone Number
___________________________________________________________________________
Name
Phone Number
___________________________________________________________________________
Name
Phone Number
Thank you for providing this information and for your interest in the Teen Camp
Program. A UHF staff member or a Teen Committee volunteer may contact you
to discuss this information.
Consent Forms
Permission to Participate in Activities and to Use Provided Transportation
I hereby give permission for the above-named teen to participate in all teen activities and to
use provided transportation. I freely waive all rights to any future claims against the Utah
Hemophilia Foundation, Camp Wapiti, volunteers, or representatives due to any accident,
injury and/or illness or treatment of the same that may occur during the camp period.

Yes

No
____________________________________________________
Signature of Parent or Legal Guardian
Teen Signature
Agreement to Comply with Camp Tobacco Policy
I understand that smoking or the use of tobacco products by minors is illegal in the State of
Utah and is not allowed during the Teen Leadership Program. I agree that teens who violate
this policy may be expelled from the program and that their families may be required to arrange
and/or pay for that teen’s transportation home. I hereby attest that I have explained this policy
to the above-named teen.

Yes

No
____________________________________________________
Signature of Parent or Legal Guardian
Teen Signature
Permission to Participate in Educational Programs
I hereby give permission for the above-named teen to participate in educational programs
during the program, including general health education and home infusion therapy training,
if appropriate.

Yes

No
____________________________________________________
Signature of Parent or Legal Guardian
Teen Signature
Release of Graphic/Photographic Rights
I hereby grant the release of any film, video or other photographic images of the above-named
teen and of any artwork created during the Teen Leadership Program by said teen for use by
the Utah Hemophilia Foundation for fundraising, educational, or other purposes.

Yes

No
____________________________________________________
Signature of Parent or Legal Guardian
Teen Signature
Teen Leadership T-Shirt Size:



Child’s Medium (10-12)
Child’s Large (14-16)
Adult Small



Adult Medium
Adult Large
Adult X-Large

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Adult 2XL
Other:___________
Teen Leadership Program
Program Commitment Agreement
This form explains and clarifies the mutual commitment between the teen
applicant and the UHF. By completing this form, you acknowledge your understanding of
and commitment to these expectations. Please initial after each to acknowledge you have
read, understand, and agree to comply.
As a Teen Leadership participant, I understand that I am committing to:
Work constructively as a part of a team with other staff and to positively resolve all
conflicts.
Teen’s Initials:__________
Place the best interest of this program above my own personal feelings.
Teen’s Initials:__________
Represent the UHF professionally and positively to other volunteers, teens, and the public.
(including not bad-mouthing anyone associated with the UHF or its partners).
Teen’s Initials:__________
Respect the confidentiality and privacy of teens and families.
Teen’s Initial:__________
Notify the UHF of any potentially unethical situation or conflict involving myself or other
volunteers.
Teen’s Initials:__________
Provide opportunities for each teen to be successful at some experience and feel good
about their experience.
Teen’s Initials:__________
Set a good example for teens through appropriate speech, positive attitude, participation in
activities, sportsmanship, sharing, and doing daily chores.
Teen’s Initials:__________
Help enforce all regulations and safety rules.
Teen’s Initials:__________
Refrain from having any personal visitors (family members and friends not associated with
the Teen Leadership Program) during the week.
Teen’s Initials:__________
Acknowledge that during the Teen Leadership Program, teens (along with adult volunteers) are responsible for teaching and carrying out planned camp activities.
Teen’s Initials:__________
Recognize that the Teen Leadership Program is for and about bleeding disorders and not a
time to develop personal, business, or social contacts. Teen’s Initials:__________
Carry out assignments and stay with them at ALL assigned camp activities.
Teen’s Initials:__________
I understand that failure to comply with this Code of Conduct may result in my dismissal from the Teen
Leadership Program and may prevent me from participating in future UHF activities.
Signature of Teen Leadership Applicant
Date
Signature of Parent or Legal Guardian
Date
Teen Leadership Program
Teen Code of Honor
We expect all teens to follow the behavior expectations outlined below.
BEHAVIOR EXPECTATIONS
1. I understand that everyone at the Teen Leadership Program needs to be treated with respect
and I need to show respect for others’ personal belongings, privacy, and feelings. Any inappropriate
touching between campers or counselors is not allowed. As well as using other’s personal belongings
without permission. I understand that I can be sent home if I violate any of these expectations.
2. I understand that it is against UHF rules to be involved with smoking, alcohol use, illegal
drugs, weapons (including pocket knives), vandalism, theft, or any other illegal behavior. I know and
understand that I could be sent home if I have brought any of these items to camp or use them;
or if I engage in ANY illegal behavior, including vandalism and theft.
4. I understand that it is against camp rules to leave the program facility unless I am on a
special, escorted and approved activity or for a medical emergency that requires transportation to an
outside medical facility. I know and understand I will be sent home if I leave facility premises
without permission.
5. I understand that I need to respect the facility and its equipment. I understand that my
parents and I will have to pay for any damage I intentionally cause.
6. I understand that I have to sleep in my assigned cabin each night. I understand it is against
camp rules to “sneak out” of my cabin after curfew and that I can be sent home for this behavior.
7. I understand that at any time if any staff member or another teen feels that I am a danger to
myself or anyone else, because of my behavior or something that I have said, I will be required to talk
to a member of the Camp Valor Committee. I understand that I can be sent home if the director
feels that it is necessary for my safety or the safety of others.
8. If I have any problems, I know and understand that I can go to my counselor or any of the
adult leaders at the Teen Leadership Program.
CONSEQUENCES
Depending on the severity of the situation, one or more of the following consequences will be taken:
I understand that my leader or a member of the Teen Leadership Committee will discuss the
behavior with me.
I may be not allowed to participate in a planned activity.
A member of the Teen Leadership Committee may call my parents and discuss the behavior with
them.
I understand that I can be sent home immediately and possibly not be allowed to participate in
future UHF activities, even if it is my first time not following any of the behavior expectations.
I understand that if I am sent home for any reason my parents will be responsible for coming to
pick me up at camp. This will be at my parent’s expense. They will not be reimbursed for travel
time, time taken off work, gas, etc.
My signature indicates I have read and understand the Behavior Expectations and agree to the
Consequences.
_____________________________
Teen Signature
_________________________________
Parent/Guardian Signature
__________
Date Signed
CAMP VALOR 2015
Teen Medical Form
This completed / signed medical form is REQUIRED to participate in Camp Valor
This completed form must be sent to Penni Smith @ IHTC (contact information on last
page)
Form must be completed and signed by your medical professional (parent signature,
only, will not be accepted).
Teens who do not submit a completed medical form will not be allowed to attend Camp
Valor.
Teens must have a confirmed diagnosis of a bleeding disorder to participate in the Teen
Camp Program.
Teen Last Name
First Name
Preferred Name/Nickname
_____________________________________________________________________
Address
City
State
Zip
(____)________________________________________________________________
Home Phone Number
Birth Date (MM/DD/YYYY)
_____________________________________________________________________
Weight
Height
Male/Female
__________________________________________________(____)______________
Parent or Legal Guardian Name
Cell Phone Number
_____________________________________________________________________
Parent/Guardian Email Address
Please list ALL medicines this individual currently uses, including pain medications:
Medication
Dose
Frequency
Special Instructions (w/ meals, etc.)
____________________ _________ _________ __________________________
____________________ _________ _________ __________________________
____________________ _________ _________ __________________________
____________________ _________ _________ __________________________
____________________ _________ _________ __________________________
Necessary medications for the week of camp should be sent with the camper’s/teen’s
name clearly marked. All medications will be dispensed by the medical staff.
Emergency Contact Information
Please provide information for two (2) individuals who are able to be contacted regarding an
emergency situation in the event that the camp medical staff is unable to reach the parents or
guardians. Also provide contact information for the teen’s physician.
___________________________________________________(____)_____________
Emergency Contact Name
Relationship to Teen
Phone Number
___________________________________________________(____)_____________
Emergency Contact Name
Relationship to Teen
Phone Number
_____________________________________________________________________
Teen’s Physician
(____)______________________________(___)_____________________________
Office Phone
Emergency/Other Phone
Health Insurance Information
Proof of insurance is required for campers/teen’s to attend camp—NO EXCEPTIONS.
Please provide a copy of both sides of your insurance card.
Name of Provider, HMO, PPO: ______________________________________________
Policy Number: ________________________ ID/Group Number: __________________
Policy Holder’s Name: ______________________ Member Number: ________________
Is pre-certification required?:

Yes

No
Phone number:________________
Parent Consent Form
Authorization for Medical Treatment
I hereby authorize physicians and/or nurses to provide the above-named teen with appropriate
medical treatment for his/her bleeding disorder or any other medical problems that may arise
during the camp period. I understand that the camp medical staff will supervise treatment of
bleeding episodes and of routine illnesses. I further understand that I may receive notification
of treatment administered to the above-named teen and that copies of any treatment records
made during camp may be sent to my private doctor or hemophilia treatment center for
continuity of treatment. I also authorize the above-named teen to be transferred to a medical
facility for emergency treatment at the discretion of the physician, nurse, camp director, or
foundation representative. I will send a sufficient supply of factor and/or other medications
needed to cover my teen’s needs.

Yes

No
____________________________________________________
Signature of Parent or Legal Guardian
Date
Authorization for Camp Medical Staff to Contact Camper/Parent After Camp:
I hereby authorize a member of the Camp Valor Medical Staff to contact me and/or my teen to
provide follow-up information and/or instruction about infusion techniques and/or further
infusion classes.

Yes

No
____________________________________________________
Signature of Parent or Legal Guardian
Date
Blood Type: _________
Type of Bleeding Disorder:

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
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Factor 8 _____%
Factor 9 _____%
Severity of Bleeding Disorder:

Platelet Disorder
vWD
Mild

Moderate


Other _________________

Severe
None
Has this individual ever been treated with factor concentrate?


Yes
No
Please note: Campers/teens who require factor treatment or are on prophylaxis must bring
their own supply of factor to camp with them. All campers with ports or similar medical devices
must bring any necessary medical supplies (i.e. port access needles, etc.). All containers
MUST be carefully labeled with the camper’s/CA’s name and any pertinent information.
Brand and product this individual currently uses: _________________________________
Purity: ______________
Average Dose Required (# of units): _____________________
On average, how often is treatment required?____________________________________

Is this individual on prophylaxis?
If yes, circle which days: Sun
Mon
Yes
Tues

No
Wed
Thu

Has this individual ever had a reaction to treatment?
Fri
Sat

Yes
Sun
No
If yes, specify product: ______________________ Reaction: _____________________
_____________________________________________________________________
Does this individual have target joints or recurrent bleeding sites?

Yes

No
If yes, please specify: _____________________________________________________
Does this individual have any of the following?:

Port

Broviac

Other
Please specify care/routine: ________________________________________________
Dietary restrictions: _______________________________________________
Please Note: First-time teen participants must include a copy of their immunization
record.
Are all immunizations up to date?

Yes

No
Date of Last Tetanus Shot: __________________________
Please indicate any serious illnesses this individual has:
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Allergies
Asthma
Diabetes
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Epilepsy
Heart Disease
Hepatitis
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HIV
Kidney Disease
ADHD or Nervous Disorders
Other __________________________
Details of all items marked above: ____________________________________________
_____________________________________________________________________
Physical limitations and required accommodations: _______________________________
_____________________________________________________________________
Please describe any recent injuries this individual has had: __________________________
_____________________________________________________________________
If this individual has a bleeding episode, what is the treatment you provide at home?
___________________________________________________________________________
___________________________________________________________________________
What else should the staff be aware of? (Behavioral issues, psychological concerns, ):
_____________________________________________________________________
_____________________________________________________________________
Medical Professional Signature:
Signature _____________________________________________
Phone:_______________________________
Date:______________________________
Date of latest Hemophilia Treatment Center visit: _________________________________
Send this completed medical form to:
Penni Smith
Intermountain Medical & Thrombosis Center (IHTC)
Primary Children’s Medical Center
100 No. Mario Capecchi Drive
Salt Lake City, UT 84113
Email: [email protected]
Fax: 801-662-4838