A World Free of MS

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MS Adventure Camp - WI Overview

MS Adventure Camp will take place at YMCA Camp Icaghowan in Amery, WI from June 20-25, 2022. This camp is for youth going into grades 4-12 who have a parent with MS or a residing household member who has MS. Applications will be evaluated on a case-by-case basis for acceptance. Applications will no longer be received after May 27.

Important note: This form must be filled out by the parent or guardian of the child(ren) interested in attending MS Adventure Camp. A separate application must be filled out for each child interested in attending camp.

Space at camp is limited; incomplete applications or those received after the application closure date may be placed on a waiting list.

This application form does not guarantee acceptance. Families will not receive notice of their acceptance to MS Adventure Camp until after the application deadline date has passed. At that time, families will be asked to complete additional paperwork necessary for attending camp.

Please do not send payment at the time of application. Upon acceptance you will be asked to submit payment for camp. The fee to attend camp is $300 per camper. During the acceptance process, payment will be requested and is a pay-what-you-can system. We do request a minimum payment of $25 per family, up to the full amount of $300 per camper. No one will be turned away because of inability to pay.

All participants are responsible for their own transportation to and from camp.

Please note that upon completing this application, you may be contacted by a Society staff member or the MS Adventure Camp Behavioral Specialist. This check-in is done to determine how to give your child the best MS Adventure Camp experience possible.

MS Adventure Camp - WI COVID Policies

The health and safety of staff, volunteers, and our communities is a top priority as we move through the COVID pandemic together and we would like you to be aware of the following safety guidelines prior to camp. Changes in safety protocol may be required due to special circumstances or local mandates. Stay tuned to all communication about MS Adventure Camp so you can be prepared.

Campers and volunteers will be expected to show proof of a negative COVID test taken within 72 hours of arrival at camp. Rapid tests will be available on-site for families who do not have access to a test.
While vaccinations are not required for campers or volunteers to attend MS Adventure Camp, we strongly encourage everyone get vaccinated to help prevent the spread of COVID-19. Additionally, COVID-19 vaccines are mandatory for all Society employees as of January 2022. All YMCA Camp Icaghowan staff will be vaccinated or tested regularly.
All attendees, regardless of vaccination status, are required to wear a mask indoors except while eating or drinking. Masks will also not be required in camper cabins. There may be some activities during which masks outdoors will be required. In all other instances, masks outdoors will be strongly encouraged.
Society events are planned to allow for physical distance between staff, volunteers and participants whenever possible.
We follow CDC guidelines for routine cleaning and sanitizing of restrooms, shared spaces, and high-touch surfaces, as well as ensure adequate handwashing supplies and/or hand sanitizer.
Keep your child home if they experience any COVID-19 symptoms within 24 hours prior to MS Adventure Camp or are exposed to anyone who is positive for COVID within 14 days prior to MS Adventure Camp.

Please contact Krista Harding at 612-335-7937 or krista.harding@nmss.org with questions.

1.

Please complete the following with parent name and information.

If you have previously registered, please login here to prepopulate your information.

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State/Province Required	ZIP/Postal Code Required

*

Phone Number: Required

Yes, I would like to receive important e-mail updates - including event announcements - from the National MS Society.

Yes, I would like to receive important postal mail updates - including event announcements - from the National MS Society.

Keep me logged in. What's this?

Please enter a username and password that you can use when you return. You can use this password to update your information or receive personalized content.

*	Username: Required	5 to 60 characters
*	Password: Required	12 to 99 characters
*	Confirm Password: Required

*2.

Question - Required - Child's first name:

*3.

Question - Required - Child's last name:

4.

Question - Not Required - Youth's preferred name (nickname):

*5.

Question - Required - Please indicate your child's gender.

Male

Female

Nonbinary

My child's gender is not listed

Prefer not to say

*6.

Question - Required - In order for us to appropriately and respectfully address your child, please indicate their preferred pronouns.

She/her/hers

He/his/him

They/them/their

My child's pronouns are not listed

*7.

Question - Required - Youth's date of birth:

Month

Day

Year

*8.

Question - Required - Youth's age (as of the first day of camp):

*9.

Question - Required - Grade in school child will enter in upcoming school year:

*10.

Question - Required - Youth's height (in feet and inches):

*11.

Question - Required - Youth's weight (in pounds):

*12.

Question - Required - Address (if same as above write "same")

(Maximum response 255 chars, approx. 5 rows of text)

*13.

Question - Required - What is your home phone number:

*14.

Question - Required - What is your cell phone number:

15.

Question - Not Required - What is your office phone number:

*16.

This camp is for youth who has a parent with MS or who lives in a household with someone with MS. Who in this child's family has MS?

(Select one of the available choices or enter a different value.)
Question - Required -

17.

Question - Not Required - If other person in household has MS, please indicate relationship.

(Maximum response 255 chars, approx. 5 rows of text)

*18.

Question - Required - Please provide information for a second parent/legal guardian, including name, home phone, cell phone, work phone, email address and mailing address if different from child's.

*19.

Question - Required - Please provide an emergency contact including name, phone and relationship, if parents/guardians are not available:

(Maximum response 255 chars, approx. 5 rows of text)

*20.

Question - Required - Please list the people authorized to pick up your camper from camp as well as their relation to your child.

21.

Question - Not Required - Please list the people who are NOT authorized to pick up your camper from camp.

*22.

Question - Required - If accepted, camp materials are available in both paper and electronic versions. Please let us know which way you would prefer to receive these documents.

On paper via mail

Electronically

*23.

Question - Required - Please list the e-mail address where you'd like to receive information about camp:

Camper Health Information

This information will be kept on file with the National MS Society and shared with camp medical staff as needed. It's used to evaluate our ability to best support you camper and facilitate a safe and enjoyable experience for youth, volunteers, and staff. Confidentiality is respected.

Please note that you will be required to provide a copy of your child's health insurance card. In addition, parent(s)/guardian will assume the full cost of any medical or hospital expenses incurred at MS Adventure Camp.

*24.

Question - Required - Name of youth's primary health clinic:

(Maximum response 255 chars, approx. 5 rows of text)

*25.

Question - Required - Primary clinic's phone number:

*26.

Question - Required - Name of youth's primary physician:

*27.

Question - Required - List any special dietary needs, including vegetarian (no meat or fish), lactose intolerant, gluten free, allergies, etc. If your child does not have any special dietary needs, please answer "N/A."

(Maximum response 255 chars, approx. 5 rows of text)

*28.

Question - Required - Date of last tetanus shot:

Month

Day

Year

*29.

Question - Required - Date of last DPT shot:

Month

Day

Year

*30.

Question - Required - Date of last measles shot:

Month

Day

Year

*31.

Question - Required - Date of last rubella shot:

Month

Day

Year

*32.

Question - Required - Date of last polio shot:

Month

Day

Year

*33.

Question - Required - Date of last mumps shot:

Month

Day

Year

*34.

Question - Required - Date of last HIB shot:

Month

Day

Year

35.

Question - Not Required - Date of last COVID vaccine:

Month

Day

Year

36.

Question - Not Required - Chronic Concerns: Check all that pertain to this camper.

	Asthma
	Convulsions/Epilepsy
	Bed wetting
	Diabetes
	Hypertension
	Sleep disorder
	Frequent ear infections
	Surgeries
	Bleeding/clotting disorders
	Heart defect/disease
	Other

37.

Question - Not Required - Provide information about supportive health care needed for each checked item (i.e. normal peak flow, normal blood sugar, etc.). If applicable, a campers' daily health care management plan can be sent directly to Krista Harding at krista.harding@nmss.org.

*38.

Question - Required - Does this camper have a history of illness, injury or surgery that would affect participation?

39.

Question - Not Required - If yes, please explain.

(Maximum response 255 chars, approx. 5 rows of text)

*40.

Question - Required - Are there any camp activities from which the camper should be exempted for health reasons?

41.

Question - Not Required - If yes, please explain.

(Maximum response 255 chars, approx. 5 rows of text)

*42.

Question - Required - Does your child have any behavioral issues or special considerations? This includes, but is not limited to ADD, ADHD, depression, anxiety, bed wetting, sleep walking, problems getting along with other kids, issues with authority figures, etc. (If not, write "none")

43.

Question - Not Required - If yes, please explain.

*44.

Question - Required - Is your child receiving services either at or outside school from a special education department, school counselor, social worker or therapist?

45.

Question - Not Required - If yes, please explain.

*46.

Question - Required - Has your child had any serious illnesses, accidents, operations or hospitalizations during the past year?

47.

Question - Not Required - If yes, please explain.

(Maximum response 255 chars, approx. 5 rows of text)

*48.

Question - Required - Does your child have any allergies? This includes, but is not limited to, medical allergies, food allergies, environmental allergies, etc.

49.

Question - Not Required - If yes, please list and include the severity of their allergy.

Medication

All medications will be collected by the Camp Health Care Provider and will be kept in the camp Health Service Building. Please send only enough medication to last the entire session.

*50.

Question - Required - Is your child is receiving any over-the-counter or prescription medication at home or school?

51.

Question - Not Required - If yes, please explain the reason for the medication.

(Maximum response 255 chars, approx. 5 rows of text)

*52.

Question - Required - For prescription drugs, a physician must complete and sign a separate form that will be sent upon acceptance to camp that provides information about medications, dosages, times and side effects information. Does your child take any prescription medication?

*53.

Question - Required - For prescription medications, please list the medication, dosage, times to be given and any known side effects. (If none, write "none".)

(Maximum response 255 chars, approx. 5 rows of text)

Over the Counter Medications: We will be providing the medications listed below through the Camp Icaghowan Healthcare Center. If your child uses an over the counter medication that is listed, you do NOT need to send that medication to camp. If your camper takes a medication that is NOT listed, you may send the amount they will need for their stay at camp in its original packaging. Please include that medication in your child's medication list.

54.

Question - Not Required - Please check the box next to any over the counter medication in the list below that you DO NOT want the health care staff to administer to your child:

	Acetaminophen (similar to Tylenol), swallowable and chewable
	Ibuprofen (similar to Motrin, Advil), swallowable and chewable
	Antihistamine (similar to Benedryl), swallowable and chewable
	Calamine, Caladryl or anti-itch
	Antibiotic Ointment (similar to Polysporin or Neosporin)
	Hydrocortisone Cream
	Antacid (similar to Tums)
	Pepto Bismal
	Antifungal Ointment or Spray
	Diamode (for diarrhea or upset stomach)
	Robitussin (for cough)
	Loradamed (similar to Claritin)

Camper Experience

The following questions are asked to allow camp volunteers and staff better know your child in order to provide a positive, healthy, and safe experience for all campers. The information provided will be shared with camp volunteers and staff as needed. Confidentiality is respected.

*55.

Question - Required - Has your child attended an overnight camp before? If yes, please describe how long they were away and their experience.

*56.

Question - Required - Does your child make friends easily? Please respond with "yes" or "no" and leave any additional comments that you feel would be helpful for camp staff.

(Maximum response 255 chars, approx. 5 rows of text)

*57.

Question - Required - Does your child express feelings openly? Please respond with "yes" or "no" and leave any additional comments that you feel would be helpful for camp staff.

(Maximum response 255 chars, approx. 5 rows of text)

*58.

Question - Required - What is the most effective way for addressing and modifying your child's behavior when they're having a difficult time following rules or instructions?

(Maximum response 255 chars, approx. 5 rows of text)

*59.

Question - Required - Do you anticipate your child having any adjustment problem to camp living? Please explain.

(Maximum response 255 chars, approx. 5 rows of text)

*60.

Question - Required - In what areas do you expect your child to excel at camp?

*61.

Question - Required - Do you foresee your child being homesick at camp? Please respond with "yes" or "no" and leave any additional comments that you feel would be helpful for camp staff.

(Maximum response 255 chars, approx. 5 rows of text)

*62.

Question - Required - Does your child regularly experience nightmares, talking in sleep, bedwetting or sleepwalking? Please respond with "yes" or "no" and leave any additional comments that you feel would be helpful for camp staff.

(Maximum response 255 chars, approx. 5 rows of text)

*63.

Question - Required - Has your child experienced any recent life changes that may affect their time at camp (divorce, death in the family, etc.)?

*64.

Question - Required - Please provide additional details about your child on this page. Keep in mind that the more we know about your child, the better able we are to provide them with a happy and healthy camp experience.

Please indicate your agreement and understanding by placing your initals next to each of the remaining items:

*65.

Question - Required - My child is aware they have a parent or someone in their household with MS:

*66.

Question - Required - I have listed any medical concerns my child might have at camp:

*67.

Question - Required - I have clearly explained any emotional or behavioral issues my child currently has (ADHD, depression, drug treatment, currently being seen by a therapist or social worker, etc.):

*68.

Question - Required - I understand that if my child has emotional or behavioral concerns, Society and camp staff will work with me to put into place a behavior management plan for camp; but in some cases the camp may not be able to meet my child's needs.

*69.

Question - Required - I understand that the camp director(s) may send a child home at their discretion. Camp directors make these decisions based on the camp's ability to properly support a child and the impact a child is having on other campers. During camp, I could be asked and will be expected to come and get my child from camp.

*70.

Question - Required - My child and I agree to follow camp rules by refraining from sending my child to camp with: any kind of snack food, pop, chewing gum, candy, beverages, electronic games, computers, radios, music players of any kind, electrical appliances, tobacco, alcohol, drugs or any related paraphernalia.

*71.

Question - Required - I understand that the National MS Society prohibits my child from having their cell phone at camp. I agree to ensure that my child's cell phone will be left at home with the knowledge that prompt emergency communication with my child can be coordinated through the Camp Director.

*72.

Question - Required - My child wants to attend MS Adventure Camp.

*73.

How did you hear about MS Adventure Camp?

(Select one of the available choices or enter a different value.)
Question - Required -

74.

Question - Not Required - I'm interested in carpooling with other families to camp and give permission to the Society to distribute my name, email address and hometown to other interested parents. Please note that further coordination around carpooling remains the full responsibility of each family as the National MS Society assumes no liability for any ensuing carpool travel arrangements.

OVERNIGHT PROGRAM RELEASE AND WAIVER OF LIABILITY

For consideration of attendance at MS Adventure Camp at YMCA Camp Icaghowan to be held from June 20-25, 2022 I waive and release the National Multiple Sclerosis Society (“Society”), its chapters, directors, officers, administrators, representatives and executors, past and present employees, volunteers, agents, supervisors, participants, all state and local governments, assigns, all sponsors, their representatives and successors(collectively, the “Releasees”), from any and all claims, liabilities, or cause of actions arising out of an injury to me (or my child) and from any and all claims, liabilities, or cause of actions arising from my (or my child’s) attendance in and transportation to and from this Event.

Inherent and Potential Risks

I understand that attending MS Adventure Camp may involve strenuous physical activity, exposure to the outdoors, animals, wildlife, and natural hazards. I understand that these activities, by their very nature, carry with it certain inherent risks. I assume all risks associated with attending MS Adventure Camp including all risks relating to strenuous physical activity, exposure to the outdoors, animals, wildlife, and natural hazards. I acknowledge that I may incur minor injuries, major injuries, and catastrophic injuries including paralysis and death. I assume risks from contact with other participants, negligent or wanton acts of other participants, failure of other participants and non-participants from observing the guidelines of the Event, any defects of conditions of premises, and the effects of weather including high heat, thunderstorms, lightning, precipitation, cold temperatures, high winds, and/or humidity.

I assume all risks associated with consuming any food or drink available at the event. I am solely responsible for any adverse health effects from food or beverage consumption, regardless of any allergy, known or unknown, that I (or my child) may have.

I agree to follow the Society’s Event Guidelines and will follow the specific rules, regulations and guidelines established by MS Adventure Camp.

I agree to dress myself (or my child) appropriately as to mitigate risk of physical injury to myself (or my child) including, but not limited to: wearing shoes appropriate for strenuous physical activity involved in MS Adventure Camp; and dressing in conjunction with the weather.

I agree that the Releasees are not responsible for any personal items or property lost or stolen before, during, or after MS Adventure Camp.

Weapons are strictly prohibited at Society events. I agree not to bring a weapon of any kind to the event, including all Society sponsored pre and post event activities.

Medical Evaluation

I attest that I (or my child) am medically and physically able to participate in MS Adventure Camp. If I experience any doubt as to my (or my child’s) ability to successfully and safely participate in and/or complete MS Adventure Camp, I take full responsibility for consulting a physician. I attest that, if I (or my child) am pregnant, disabled in any way, or have recently suffered an illness, injury, or impairment, I (or my child) should have or did consult a physician prior to participating in MS Adventure Camp.

I consent to emergency medical care and transportation in order to obtain treatment in the event of injury to me (or my child) as medical professionals may deem appropriate. This Release extends to any liability arising out of or in any way connected with the medical treatment and transportation provided in the event of an emergency, including, but not limited to, negligence emergency rescue operations.

Voluntary Participation

I am fully aware of the risks connected with participation in MS Adventure Camp, whether specifically listed in this Release or not, and I voluntarily elect to participate in MS Adventure Camp knowing that this participation involves these risks.

Assumption of Risk, Waiver of Liability, Release, and Covenant Not To Sue

In consideration for being permitted to participate in MS Adventure Camp, I voluntarily agree for myself, my family, heirs, assigns, executors, and administrators to the following:

1. TO ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, OR PERSONAL INJURY, INCLUDING DEATH that may be sustained by me (or my child), or any loss or damage to property owned by me (or my child), as a result of participating in MS Adventure Camp.

2. TO RELEASE, WAIVE, HOLD HARMLESS, DISCHARGE, AND COVENANT NOT TO SUE the Releasees from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action whatsoever, that I might have or may acquire in the future, arising out of or related to any loss, damage, or injury, including death, that may be sustained by me (or my child), or to any property belonging to me (or my child), while participating in MS Adventure Camp including, but not limited to, any claim that the act or omission complained of was caused in whole or in part by the negligence or carelessness of the Releasees.

COVID-19 Acknowledgement

I hereby acknowledge and understand that the 2019 novel coronavirus (“COVID-19”) is extremely contagious and easily spread through air, person-to-person contact, and contact with contaminated objects. People can be infected and show no symptoms yet still spread the disease, which can cause serious and potentially life-threatening illness and even death.

Further, I knowingly and voluntarily agree to follow all required and relevant federal, state, local, and Society guidelines and recommendations to maintain the health and safety of event attendees. I acknowledge that failure to comply with these practices may result in exposure to, or contraction of, COVID-19 and may put others at risk. Prior to the event, I acknowledge and agree that I will fully and truthfully fill out and sign any waivers, releases, and/or questionnaires that may be required of me by the Society as a condition to participate in the event.

Acknowledgment and Compliance with Rules

I agree to observe and obey all rules and safety procedures that accompany MS Adventure Camp and to abide by any decision of an event official relative to my (or my child’s) ability to safely compete in the event. I agree to exhibit appropriate behavior at all times and to obey all laws. Society and event officials may dismiss me (or my child), without refund, should my (or my child’s) behavior endanger the safety of or negatively affect an event, person, facility, or property of any kind.

Severability

I agree that if any portion of this Release is deemed to be invalid, the remainder of the Release will still be binding and enforceable.

I, the parent(s) or guardian(s) of the above-named participant, hereby give my/our approval to this child’s participation in MS Adventure Camp. I represent and warrant that I am legally authorized to sign on the participant’s behalf. I assume all risks and hazards incidental to such participation, and I hereby waive, release, absolve, indemnify, and agree to hold harmless Releasees for any claim arising or of an injury to my/our child and from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action whatsoever arising out of or connected with my/our child’s participation in and transportation to and from MS Adventure Camp. I consent to the foregoing and grant permission for my/our child to participate in MS Adventure Camp. I acknowledge I have carefully read, accept, and agree to the terms on this Release, and know and understand their contents and I sign the same on my/our own free act and deed.

Sign Off

I, the parent(s) or guardian(s) of the above-named participant, hereby give my/our approval to this child’s participation in MS Adventure Camp. I represent and warrant that I am legally authorized to sign on the participant’s behalf. I assume all risks and hazards incidental to such participation, and I hereby waive, release, absolve, indemnify, and agree to hold harmless Releasees for any claim arising or of an injury to my/our child and from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action whatsoever arising out of or connected with my/our child’s participation in and transportation to and from MS Adventure Camp. I consent to the foregoing and grant permission for my/our child to participate in MS Adventure Camp. I acknowledge I have carefully read, accept, and agree to the terms on this Release, and know and understand their contents and I sign the same on my/our own free act and deed. I attest that my/our child, the above-named participant, is a minimum of 8 (minimum age) years of age as of the date of MS Adventure Camp, and that he or she will be accompanied by an adult eighteen years of age or older throughout his or her participation in MS Adventure Camp.

*75.

Question - Required - I acknowledge and represent that I have carefully read, accept, and agree to the terms on this Release and Waiver of Liability stated above, and know and understand their contents and I sign the same on my own free act and deed.

Yes, I confirm.

*76.

Question - Required - Please provide your full name.

*77.

Question - Required - Please indicate your relationship to the camper for whom you are submitting an application.

Photography and Website Release

I hereby grant full permission to Society to use, reuse, reproduce, publish, or republish any photographs, motion pictures, recordings, or any other record of my participation in this event, including all Society sponsored pre and post event activities, in any medium now known or hereafter developed, alone or in conjunction with other material, without restriction as to changes or alterations, as well as to use my name, voice, likeness, and/or other indicia of identity, for editorial, educational, promotional, advertising, and commercial purposes, including without limitation in connection with the solicitation of contributions and the furtherance of the corporate objectives of Society. Further, I relinquish all rights, title, and interest in any and all photographs, motion pictures, recordings, or other records of MS Adventure Camp I may take or capture to Society.

I grant permission for the Society to publish and recognize my participation in Event on its website and have reviewed and consented to the Society’s Online Privacy Policy found at www.nationalmssociety.org/Helpful-Links/Legal-Notice-Privacy-Policy/Privacy-Policy.

*78.

Question - Required - I agree to the above Photography Release.

Home - National Multiple Sclerosis Society

2022 MS Adventure Camp - WI Camper Application