Diocese of Ogdensburg

The Roman Catholic Church in Northern New York

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The 2018 Camp Guggenheim Registration forms have gone paperless. All forms will be completed securely online except the Healthcare Provider's Orders. The online registration form will take approximately 30 minutes to complete. The form cannot be saved and must be completed in its entirety. Registrations must be submitted by June 1.

All submitted registrations must include a non-refundable $100 deposit or the full camp fee of $300. Upon completion of the form, you will be forwarded to PayPal. If you have any questions please contact, Virginia Demers at the Youth Ministry Office at 315-393-2920 ext. 1401.

Today's Date:
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Please select your 1st choice for the week the Camper would like to attend:(*)
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Please select your 2nd choice for the week the Camper would like to attend:(*)
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Is this the Camper's first time attending camp?(*)
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Camper's First Name:(*)
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Camper's Last Name:(*)
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Gender:(*)
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Age at Camp:(*)
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Date of Birth:(*)
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Parish:(*)
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Parent Information
Name(s) of Parent/Guardian the Camper resides with:(*)
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Street Address:(*)
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City:(*)
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State:(*)
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Zip Code:(*)
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Home Phone:
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Cell:(*)
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Email:(*)
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Mother/Guardian Place of Employment:(*)
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Title:(*)
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Work Phone:(*)
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Father/Guardian Place of Employment:(*)
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Title:(*)
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Work Phone:(*)
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If a parent/guardian can not be reached in case of an emergency, please contact:
Emergency Contact Name:(*)
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Relationship to Camper:(*)
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Address:(*)
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Home Phone:
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Cell Phone:(*)
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Work Phone:(*)
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Emergency Contact Name:(*)
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Relationship to camper:(*)
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Address:(*)
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Home Phone:
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Cell Phone:(*)
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Work Phone:(*)
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I give permission for my Camper to swim.
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I give permission for my Camper to use a boat (kayak, canoe, and/or paddle boat).
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I give permission for my Camper to participate in rappelling activities.
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I give permission for my Camper to participate in off site activities. (Outside Camp Guggenheim Facilities) i.e. hiking, service projects. Transportation will be provided in staff vehicles.
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I give permission for my Camper to use sunscreen and insect repellent (EPA Registration 4822-167; 4822-399; 4822-396; 4822-380).
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Camp Guggenheim will try to honor roommate requests for first-time Campers.
Name(s) of other Camper(s) child is requesting to share a room with:
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In the event the dorms are full, I give permission for my Camper to stay in a tent. Campers will be supervised by Counselors also staying in tents. The tents are on raised platforms and have a mattress for each Camper. Each Camper is given a large plastic tote to store belongings in. In the event of a thunderstorm or low temperatures, Campers will sleep on mattresses in the lounges.
I give permission for my Camper to stay in a tent.
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I received a list of items my child should/should not bring:(*)
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Section A - Travel Home
Who will pick your Camper up from Camp Guggenheim at the end of the week:(*)
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Electronic Signature of Parent/Guardian:(*)
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By typing my full name (electronic signature) above, I hereby consent to my Camper’s release from Camp Guggenheim at the end of the week.
Section B - Health History
The information provided in this section is not part of the Camper acceptance process, but is gathered to assist our staff in identifying appropriate care. The Health History section must be completed by the parent(s)/guardian(s) of minors.
Insurance Information
Is the Camper covered by health insurance:(*)
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Carrier name:
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Plan name:(*)
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Subscriber (member) Id:(*)
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A photocopy of the front and back of your health insurance card must be provided. If you are unable to upload your health insurance card, please mail a copy to the Youth Ministry Office, PO Box 369, Ogdensburg, NY 13669 or email to eforms@rcdony.org.
Insurance Card Upload:
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Healthcare Provider Information
Name of Healthcare Provider:(*)
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Phone:(*)
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Address:(*)
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Dentist/Orthodontist:(*)
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Phone:(*)
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Address:(*)
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Does your Camper have any of the following:(*)

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List any major illnesses, operations, hospitalizations, or injuries during the past year.
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Diet (check all that apply):

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Please Explain:
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Medication Allergies
Medication:
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Signs/Symptoms of reaction:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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Medication:
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Signs/Symptoms of reaction:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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Medication:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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Food Allergies
Food:
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Signs/Symptoms of reaction:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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Food:
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Signs/Symptoms of reaction:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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Food:
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Signs/Symptoms of reaction:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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Other Allergies
Other:
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Signs/Symptoms of reaction:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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Other:
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Signs/Symptoms of reaction:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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Other:
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Signs/Symptoms of reaction:
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Causes Anaphylaxis:
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Do you use an EpiPen:
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Most Recent Episode:
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For Female Camper
Has the Camper started her menstrual periods?
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If not, has she been told about menstrual periods?
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Is her menstrual cycle normal?
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General Questions (Explain “yes” answers below)
Have frequent headaches?
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Had a head injury?
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Ever been unconscious or had a concussion?
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Wear glasses, contacts or protective eye wear?
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Have frequent ear infections?
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Ever passed out during or after exercise?
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Gotten dizzy during or after exercise?
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Ever had chest pain during or after exercise?
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Had a significant joint or bone problem?
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Wear orthodontic appliances?
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Any skin problems (e.g., itching, rash, acne)?
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Had mononucleosis in the past 12 months?
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Have problems with sleepwalking?
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Any problems with diarrhea or constipation?
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Have a history of bed wetting?
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Ever had an eating disorder?
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Ever had high blood pressure?
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Ever had back pain?
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If you answered "Yes" to any of the above questions, please explain:
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Camp Guggenheim embraces the uniqueness of every individual and wants every child to have the opportunity to participate at Camp. We encourage Camper's with special needs to attend and participate at Camp.
Kindly provide us with any information to help us ensure your Camper's needs are met during their stay at Camp Guggenheim:
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Which of the following has your Camper had?
(check all that apply):

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Date of Last Mantoux Test:
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Result of Mantoux Test:
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Restrictions
Explain any restrictions to activity i.e. what cannot be done, adaptations or limitations are required?
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The Healthcare Provider's Orders must be completed by your Healthcare Provider and is due to the Youth Ministry Office by June 1. A Camper must have a physical prior to camp within the last year. Campers without a physical will not be able to attend Camp.
Please click here to print the Healthcare Provider's Orders.
Parent/Guardian Authorization:
Electronic Signature of Parent/Guardian:(*)
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By typing my full name (electronic signature) above, I hereby affirm and certify that the information provided in Section B - Health History is complete and accurate. My child has my permission to engage in all camp activities except as noted.

I hereby give permission to the Guggenheim staff to provide for my child routine health care (including over-the-counter medication as authorized on the Healthcare Provider's Orders administer prescribed medication in accordance with the written instructions of the Health Care Provider, apply sunscreen, and administer or obtain emergency medical treatment. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary transportation for my child.

I hereby grant permission to the Guggenheim staff, as “personal representative” of my child while enrolled at camp, to receive any records or results or medical treatment given to my child while enrolled at Guggenheim.

In the event I cannot be reached in an emergency, I hereby give permission to the Healthcare Provider selected by the camp, to secure and administer treatment, including hospitalization, for my child. This completed form may be photocopied for trips out of camp.

Healthcare Notification Policy
Our healthcare staff will make every effort to contact you by phone, if your child has need for out-of-camp healthcare. Because of timing and scheduling conflicts, we cannot promise that we will be successful in reaching you. In addition to phone contact, we will provide you with a written summary about out-of-camp health care given to your child. We generally do not contact you if your child is seen in the camp health center for routine problems (e.g. skinned knees, sore throat, and headache) that do not require a Healthcare Provider's referral. The decision to consult you for routine, in-camp healthcare is determined on a case by-case basis for our Healthcare Provider. You will typically be notified if your child visits the health center with a repeated complaint, or if your child’s condition does not improve in a reasonable amount of time.
Electronic Signature of Parent/Guardian:(*)
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By typing my full name (electronic signature) above, I hereby affirm and certify that I have read and understand the Health Care Notification Policy.
Over-the-counter Medications
Electronic Signature of Parent/Guardian:(*)
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By typing my full name (electronic signature) above, I hereby understand and affirm that I may not send my child to Camp with over the counter medication(s) that my Healthcare Provider has not signed for on the Healthcare Provider's Orders Form. I also understand the dosages will be administered according to the Healthcare Provider's orders. I also understand that Guggenheim staff cannot administer over-the-counter medication even if the healthcare center has it in stock if a child does not have a Healthcare Provider's Order for that medication.
Meningococcal Conjugate Vaccine:
Has your child had the Meningococcal Conjugate Vaccine:(*)
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(*)
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Please Select one of the following options regarding the Meningococcal Conjugate Vaccine:(*)
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Electronic Signature of Parent/Guardian:(*)
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By typing my full name (electronic signature) above, I hereby affirm and certify that the option I selected above is my preference regarding the Meningococcal Conjugate Vaccine.
Waiver and Release of Liability; Indemnification and Hold Harmless Agreement

In exchange for Camper’s participation in the Roman Catholic Diocese of Ogdensburg’s Guggenheim Program (“Summer Camp”), Camper, Parent(s) and/or Legal Guardian(s) of minor Campers agree as follows:

1. Acknowledgement of Risk. Camper, Parent(s) and/or Legal Guardian(s) acknowledge and fully understand that there are inherent risks of serious injury or death associated with rappelling, hiking, backpacking, biking, swimming, canoeing and other activities associated with the camp experience. These inherent risks include, but are not limited to: encountering natural dangers such as falling rocks or objects, irregular or uneven ground, unseen and unmarked objects, drowning or serious injury in and around water could occur due to water movement, subsurface conditions, cold water temperature, water impurities and the like. Inherent risks also include acts or omissions of other Campers, the condition of equipment or property, even if properly maintained; weather conditions (such as lightening strikes, sunburn, rain or hail storms, tornadoes and the like), contact with plants, animals or insects, the risk of Camper engaging in unauthorized activities, Camper’s physical conditions or Camper’s own acts and omissions, conditions or roads, trails, waterways or terrain, the administration and availability of first aid and emergency treatment and consumption of food or drink by Camper. Camper, Parent(s) and/or Legal Guardian(s) further acknowledge that the inherent risks associated with activities at Summer Camp, including rappelling, hiking, backpacking, biking, swimming and canoeing cannot be comprehensively described as part of this document.

2. Assumption of Risks. Camper, Parent(s) and/or Legal Guardian(s) hereby release, waive and discharge Summer Camp, its employees and agents from liability claims and demands of negligence on the part of Summer Camp, its employees and agents arising in connection with the participation in Summer Camp activities and use of Summer Camp facilities and equipment, including, but not limited to, those risks described in paragraph #1 above; providing, however, that this waiver and release does not include injury, damage, or loss as a result of the gross negligence of Summer Camp, its agents or employees.

3. Indemnification and hold harmless. Camper, Parent(s) and/or Legal Guardian(s) further agree to indemnify and hold harmless Summer Camp, its employees and agents, against all losses, damages, monetary awards and expenses, including all costs and attorneys fees incurred in connection with any and all claims of negligence on the part of Summer Camp, its employees and agents, brought by Camper, Parent(s) and/or Legal Guardian(s), his or her heirs, successors, assigned and legal representatives for any injury, death, illness, disease or damage to property, arising from or connected with participation in any activity of Summer Camp. The indemnification and hold harmless agreement does not include losses, damages, monetary awards and expenses as a result of the intentional or reckless acts of Summer Camp, its employees and agents.

4. Miscellaneous. The parties agree that the provisions of this “Waiver and Release of Liability; Indemnification and Hold Harmless Agreement” (“Agreement”) shall be deemed severable and that the invalidity or unenforceability of any one or more of the provisions of clauses hereof shall not affect the validity or enforceability of the other provisions or clauses hereof except as specifically set forth herein. The terms of this Agreement constitute the entire agreement and understanding between the parties. This Agreement is made pursuant to and shall be construed under the laws of the State of New York.

5. Opportunity to Negotiate. You are encouraged to carefully review the contents of this Agreement and take the time you feel necessary to review it. DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT. You may wish to consult an attorney. If you wish to negotiate any of the terms of this Agreement for modifications, deletions or additions, please contact the Roman Catholic Diocese of Ogdensburg Youth Ministry Center Director (“Director”) at (315) 393-2920 ext. 1401 prior to signing and executing this Agreement. If you do not contact the Director prior to signing and executing this Agreement, Summer Camp understands that you are accepting the terms and conditions as set forth above, and that you do not wish to pursue any further negotiations regarding the terms and conditions of this Agreement.

Electronic Signature of Parent/Guardian:(*)
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By typing my full name (Electronic Parent/Guardian Signature) above I CERTIFY THAT I HAVE READ THIS AGREEMENT AND THAT I UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS AND ASSUMING SUBSTANTIAL RESPONSIBILITIES BY SIGNING IT, AND THAT I SIGN IT VOLUNTARILY.
Electronic Signature of Camper:(*)
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By typing my full name (Electronic Camper Signature) above I CERTIFY THAT I HAVE READ THIS AGREEMENT AND THAT I UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS AND ASSUMING SUBSTANTIAL RESPONSIBILITIES BY SIGNING IT, AND THAT I SIGN IT VOLUNTARILY.
Scholarship Information
This scholarship fund assists youth who want to attend Camp Guggenheim after all other sources of funding are exhausted. It is expected that each person will pay part of the Camp Guggenheim fee. Scholarship funds are limited and cannot provide full registration fees for anyone. Please note that all individuals seeking a scholarship must also contact their parish for assistance. Remember, there is no assurance that this request will be automatically funded. You will receive notification in the mail with the results of your request. Requests for scholarships must be received by June 1.
Are you applying for a scholarship:
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Number of persons in household:(*)
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Household Income:(*)
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Please list the portion paid by Family and/or Parish and/or Other, and Scholarship amount requested in the following box.
Amount Requested:(*)
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Explanation of Need:
Please indicate below (or on an additional sheet) special information which may be helpful to the Scholarship Committee as they determine the need for this scholarship.(*)
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Electronic Signature of Parent/Guardian:(*)
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By typing my full name (electronic signature) above, I hereby affirm and certify that the information provided in the Scholarship Application is complete and accurate.
The consent for release of audio, photograph and video for campers must be completed online. Please visit https://rcdony.org/photo to fill out the form.
Verification(*)
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