Register for Camp

How did you find out about SoCA Resident Camp? Check all that apply. *

Camper Name *

First

Last

Camper Date of Birth *

Grade camper will be entering in fall 2021. *

Choose one registration option *

Camper is a registered Girl Scout with Girl Scouts in the Heart of Pennsylvania (GSHPA) Registered after Oct. 1, 2020
Camper is registered with another Girl Scout council outside of GSHPA
Camper is not a registered Girl Scout (additional fee of $25 required). I give my camper permission to become a registered member of Girl Scouts in the Heart of PA

Troop Leader's Name or Troop Number (if applicable)

Service Unit Name or Service Unit Number (if applicable)

Camper Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Parent/Guardian Name *

First

Last

Cell Phone *

Home Phone

Email *

Other Parent/Guardian Name (if applicable)

First

Last

Other Parent Cell Phone

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Parent/Guardian Permissions

By checking the boxes below, I confirm that I agree to and will adhere to these statements:

My child has permission to attend Camp Archbald resident camp and participate in all phases of activities both on and off camp property, including transportation out of camp, except as noted on the health form. I accept full responsibility of possible risk for my camper when climbing and participating in the adventure course. I agree not to hold SoCA or its representatives responsible in case of illness, accident, or loss of my child or her property during this program. *

Yes
No

Camper confirmations, packing list, directions and check-in instructions will be sent to the above listed parent/guardian email before camp. I have access to the listed e-mail and will be able to receive camp information electronically prior to attending with my camper. *

Yes
No

I acknowledge that all events and activities of the Camp Archbald resident camp (July 11-23, 2021) are sponsored and operated by the Supporters of Camp Archbald, and not by GSHPA. GSHPA is not responsible for campers during the Camp Archbald resident camp program. Under no circumstances shall I hold GSHPA or its representatives responsible in the case of any injury, illness, accident or loss of my child or her property during this program. *

Yes
No

Camper Code of Conduct - Please click both options in each question

At Camp Archbald, we want to make sure everyone has a safe and fun experience. Our camper code of conduct is based on the Girl Scout Promise and Law, and this is our guide for behavior at all Girl Scout activities and camp. Parents/guardians and girl participants, please read and discuss together then check the boxes to agree to each statement. The Girl Scout Promise: On my honor, I will try, To serve God and my country, To help people at all times, And to live by the Girl Scout Law. The Girl Scout Law: I will do my best to be honest and fair, friendly and helpful, considerate and caring, courageous and strong, and responsible for what I say and do, and to respect myself and others, respect authority, use resources wisely, make the world a better place, and be a sister to every Girl Scout. Failure to follow our Code of Conduct will result in the following corrective actions: First offense: Review of the Girl Scout Promise/Law, camp rules/policies as appropriate and an apology, if needed. Second offense: Review of the camp rules/policies as appropriate, an apology (if needed), and parent/guardian will be told of behavior. Third offense: Review camp rules/policies as appropriate with parent/guardian and child. A discussion will be held between parent/guardian, child and camp director regarding expectations for the rest of the session. Fourth offense: Camper will be sent home without the option of a refund.

I will follow the rules that are made to protect others and myself and to help make sure camp activities are safe, fun, and successful. *

Camper Agrees
Parent/Guardian Agrees

I will treat other people, myself, property, and equipment with respect. *

Camper Agrees
Parent/Guardian Agrees

I will be considerate of the feelings of others. *

Camper Agrees
Parent/Guardian Agrees

I will be respectful to the camp staff. I will not argue with staff or call them names. I will ask questions calmly and if I am disappointed, I will express my opinion in a respectful manner using appropriate language. *

Camper Agrees
Parent/Guardian Agrees

I will not bully or abuse (hit, slap, spit, or any other unwanted touch) my sister Girl Scouts. I understand that violence will not be tolerated and my parent/guardian will be notified as well as the parent/guardian of any girls involved. *

Camper Agrees
Parent/Guardian Agrees

I will remember that others have ideas and thoughts which may be different from mine, and that their ideas and thoughts are just as important as mine. I will not make fun of the ideas and thoughts of others. *

Camper Agrees
Parent/Guardian Agrees

Girls will be allowed to bring electronic devices with them to camp. However, phones must be kept on airplane mode at all times. Phones can be used for music/photos/video/reading at the appropriate times. Calling and texting will NOT be permitted while at camp, and if a camper is caught using their phone for these purposes, it will be confiscated until the end of camp. Please be aware that the camp is NOT responsible for: lost, stolen, broken or damaged devices. There is no guarantee that the camper will be able to charge any electronic device(s) while at camp. Also be aware that there is no WiFi and that cellular service can be spotty at camp. *

Camper Agrees
Parent/Guardian Agrees

Camper Health Form

Camper age when starting camp

Custodial care information *

Both parents
Mom
Dad
Other

If other, please explain.

Name and phone number of family physician *

Is camper covered by medical insurance? *

Yes
No

Name and policy/group number for medical/hospital insurance carrier. *

Date of camper's last physical exam *

Were there any medical diagnoses made at the time? *

List any camper allergies *

Click on the corresponding box based on the restrictions of your camper *

I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations which I will note below in the "other" option.

If other, please explain.

Camper dietary restrictions *

Please explain

Please indicate if your camper wears any of the following (include all other medical devices under the other option and please individually list them) *

Please explain

Immunizations *

My camper is up to date on all immunizations for her age
My camper is NOT up to date on all immunizations for her age. By clicking this box - my camper HAS NOT been fully immunized, I understand and accept the risks to my child for not being fully immunized.

Most recent date of DTap or TdaP (Diptheria/tetanus/pertussis or tetanus booster) *

Please note:

Health History - Has your camper...?

Do you have questions or need to discuss your camper's health concerns? E-mail us at residentcampforsoca@gmail.com

Ever had surgery? *

Yes
No

Had recurrent/chronic illnesses? *

Yes
No

Had a recent infectious disease? *

Yes
No

Suffered/currently suffers from hearing issues/deafness? *

Yes
No

Suffered/currently suffers from vision issues/blindness/color blindness? *

Yes
No

Suffered/currently suffers from speech issues? *

Yes
No

Suffered/currently suffers from mobility impairment? *

Yes
No

Had asthma/wheezing/shortness of breath? *

Yes
No

Had diabetes? *

Yes
No

Had seizures? *

Yes
No

Had headaches? *

Yes
No

Had fainting or dizziness? *

Yes
No

Passed out/had chest pain during exercise? *

Yes
No

Had mononucleosis (mono) during the past 12 months? *

Yes
No

Had problems with periods/menstruation? *

Yes
No

Have problems with falling asleep or sleepwalking? *

Yes
No

Ever had back/joint problems? *

Yes
No

Had a history of bedwetting? *

Yes
No

Had problems with diarrhea or constipation? *

Yes
No

Had any skin problems? *

Yes
No

Had recurrent nosebleeds? *

Yes
No

Had recurrent ear infections? *

Yes
No

Traveled outside the country in the past 9 months? *

Yes
No

Ever been treated for Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)? *

Yes
No

Ever been treated for emotional or behavioral difficulties? *

Yes
No

Ever been treated for an eating disorder? *

Yes
No

During the past 12 months, seen a professional to address mental/emotional health concerns? *

Yes
No

Had a significant life event that continues to affect the camper's life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, disaster etc.) *

Yes
No

I am aware that my camper needs to provide a negative COVID test, within 3 days prior to attending camp. *This is based on current COVID-19 recommendations, and could change.* *

Yes, I agree
No, I do not agree

Please explain any "yes" answers in detail - or add in any information about the camper's health you think is important or that might affect the camper's ability to fully participate in the camp program.

Medications

YOU CAN SKIP THIS SECTION IF YOUR CAMPER DOES NOT TAKE MEDS. ALL MEDICATIONS MUST BE IN ORIGINAL CONTAINERS. Our nurses can only administer medication according to directions on the label unless we have a signed doctor's note.

Name of medication, date medication started, reason for taking, when medicine is taken, amount/dose given, how it is given.

Health Authorizations

This health history is complete and accurate. I know of no reason(s), other than the information indicated on this form, why my camper should not participate in camp activities. I authorize the Camp Archbald resident camp nurse(s) or director to consent to medical treatment when either I or my assignee cannot be contacted. I understand every effort will be made to contact me before such action. I assume financial responsibility for emergency care if such care is not covered by GSHPA activity accident insurance. *

I agree
I disagree

I hereby authorize trained camp staff to give necessary first aid to my child. I also authorize the nurse(s) or director to obtain and consent on my behalf to whatever medical diagnosis or treatment is deemed necessary or advisable by such person for the well being of my child. *

I agree
I disagree

I understand the camp nurses will review this form and only share the information on this form on a "need to know" basis with staff. At the conclusion of camp, this document will be turned over to Girl Scouts in the Heart of Pennsylvania. *

I agree
I disagree

If any information on this form changes, I will contact camp staff at residentcampforsoca@gmail.com as soon as possible. *

I agree
I disagree

When participating in camp, my child may be photographed or recorded for print, video, or electronic media. I give my permission for images or videos to be used in promotional materials, news releases, and other published formats by Supporters of Camp Archbald (SoCA). *

I agree
I disagree

Camp staff adults have my permission to transport my camper on a group trip or in case of emergency. *

I agree
I disagree

I agree to the refund policy set forth by SoCA. Full refunds except the deposit of $25, will be given for cancellations up to the close of registration, June 1st 2021. 50% of refunds will be given after the close of registration (after June 1st, 2020) up to 2 weeks prior to camp (no later than June 28, 2020). At 2 weeks prior to camp, no refunds will be given unless in cases of severe medical emergencies with documentation. *

I agree
I disagree

By typing my full name below I agree that all of the information submitted in this form is correct and up to date. If I need to make any changes I will contact camp staff immediately at residentcampforsoca@gmail.com. *

Today's date *

Camp Selections and Payment - Payment by credit or debit card today is highly preferred, but not required.

Choose ONE program option for your camper to attend. *

Choose one ALTERNATE program option for your camper to attend in the event your program choice is full. (copy) *

Want to bunk with a friend? Add their name below. ONE name only. Please be sure your friend requests you also.

Please choose what you would like to pay. You can pay only the non-refundable $25 deposit, the full camp registration amount, or a custom amount ($25 minimum required). If payment is not received within 2 weeks of registration, your camper will lose their spot. At 2 weeks prior to camp, no refunds will be given. *

$25 deposit only
Full Camp Amount (choose the camp session below)
Amount of my choice
Not making a payment today

Please note: Go!Dough cannot be used for the $25 deposit. If you would like to pay the remainder of your camp fee with Go!Dough or a Cookie Incentive, please contact GSHPA to have your money sent to SoCA.

$25 deposit

Price: $ 25.00

How I am going to pay today? We highly recommend paying today via credit or debit card. *

Credit card - using the form below
Check - must be postmarked within 2 weeks of registration
Other

Please enter the amount you would like to pay ($25 minimum)

Girl Scout Membership Fee *

I'm already a Girl Scout and paid my membership fee for the year!
I am not a Girl Scout and need to register and pay the $25 fee.
I am not a Girl Scout but will be paying the $25 registration fee at a later date

Girl Scout Registration Fee

Price: $ 25.00

If you are paying the full amount today, please select your camper's session below.

Would you like to cover the processing fee for SoCA? (2.2% + $0.30)

Yes
No
Does not apply (not making payment today)

Credit Card Processing Fee

Total

$ 0.00

Credit or Debit Card

Card

Name on Card

Register for Camp

If you registered for camp 2020, and rolled over your deposit you DO NOT need to register again.

Parent/Guardian Permissions

Camper Code of Conduct - Please click both options in each question

Camper Health Form

Health History - Has your camper...?

Medications

Health Authorizations

Camp Selections and Payment - Payment by credit or debit card today is highly preferred, but not required.

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Register for Camp

If you registered for camp 2020, and rolled over your deposit you DO NOT need to register again.

Parent/Guardian Permissions

Camper Code of Conduct - Please click both options in each question

Camper Health Form

Health History - Has your camper...?

Medications

Health Authorizations

Camp Selections and Payment - Payment by credit or debit card today is highly preferred, but not required.

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