Camp AGAPE Participant Application (Due May 31, 2017) 지원지역 / Location: NCA Youth ( ) NCA Adults ( ) Vancouver ( ) Orange County ( ) Los Angeles ( ) East Los Angeles ( ) Irvine ( ) Torrance ( ) TRAC/PPOG/Volunteer ( ) Registering through Church / Organization: Participant Information: (PLEASE CIRCLE YOUR T-SHIRT SIZE; SIZE UP!) T Shirt Size: XS S M L XL XXL Name (Korean/ 한글 ): Name (English/ 영어 ): Date of Birth (MM/DD/YYYY): / / School/Institution ( 학교 ): Home Address: City: State: Zip Code: Home Phone ( 집번호 ): Cell Phone ( 핸드폰 ): Diagnosed Disability ( 장애명 ): Parent / Guardian Information: Please list two people; these contacts should be able to make the decision of what should be done in case of any and all emergency situations. 응급상황발생시참가자에관련된모든결정을내릴수있는권한을가진 2명의연락처를적어주십시오. Name ( 한 /Kor or 영 /Eng): Relationship ( 관계 ): Mobile ( 휴대전화 ): Home/Work ( 자택 / 직장 ): Name ( 한 /Kor or 영 /Eng): Relationship ( 관계 ): Mobile ( 휴대전화 ): Home/Work ( 자택 / 직장 ): CA-PCamp-17-1
Self Care: 1. 참가자가화장실을혼자이용할수있습니까? Is the participant capable of using the restroom without assistance? 2. 혼자식사를할수있습니까? Is the participant capable of eating without assistance? 3. 혼자옷을입을수있습니까? Is the participant capable of getting dressed without assistance? 4. 참가자가보조도구를사용합니까? ( 예, 보청기, 휠체어, 워커, 다리보조기, 등 ) Is the participant currently using any aids? (Example: Hearing aid, wheelchair, walker, etc.) Eating Habits: 5. 참가자가좋아하는음식과간식은무엇입니까? What foods does the participant like eating for meals and/or snacks? 6. 참가자가싫어하는음식과간식은무엇입니까? What foods does the participant dislike eating for meals and/or snacks? CA-PCamp-17-2
7. 특별한식단이필요합니까? Is the participant in need for a special meal plan? 8. 참가자의식습관에대해자세히적어주십시오. ( 알러지있으면기입해주세요 ) What is the participant s eating habits? (Please indicate if the participant is allergic to any type of food) Behavior: 9. 참가자의행동상의특징을적어주십시오. ( 예, 다른사람을물거나, 때리는지, tantrum 이있는지등에대해 ) What behaviors should we be aware of? (Biting, hitting and/or any aggressive behaviors) 10. 참가자를달랠때주로어떤방법을사용합니까? What techniques do you use to comfort and/or calm the participant? 11. 참가자가모르는사람과있을때어떻게행동합니까? What behaviors does the participant show when meeting new people? 12. 참가자가무서워하거나두려워하는상황이있습니까? When and what is the participant afraid/scared of? CA-PCamp-17-3
Communication: 14. 참가자는원하는것을어떻게표현합니까? ( 예, 목이마를때, 화장실가고싶을때 ) How does the participant show what he/she wants? (When thirsty, wanting to go somewhere, etc.) 15. 참가자가수화나 PECS, 글쓰기판을사용해서의사소통을합니까? Does the participant use any aids to communicate? (Sign language, PECS, writing, drawing, etc.) 16. 참가자를모르는사람이참가자의말을잘알아들을수있습니까? Would a stranger be able to listen and understand when the participant speaks? Disability: 17. 참가자가지병이나장애로잘작을한적이있습니까? 발작을한적이있다면언제, 어떻게, 어떤반응을보이는지설명해주세요. Does the participant have a history of having seizures? If so, how long ago, and how severe was the seizure? 18. 참가자가약을복용할때저희가알고있어야할유의하상이있습니까? When the participant takes their medication, are there reactions that we must be aware of? 19. 참가자의장애 / 약 / 건강과관련해저희에게특별히요청사항하시는것이있습니까? Are there any other health concerns / specific requests that we must know of? CA-PCamp-17-4
Camp AGAPE Medical Release Form 알러지혹은질병 Allergies (food, medication, etc.) and Illnesses 비상시연락할담당의사이름및연락처 Name & Contact Number of Doctor 의료보험명 Name of Medical Insurance 의료보험번호 Medical Insurance Policy Number 복용중인약이름및복용용량 / Medication currently taking: Name of Medication Dosage Morning Afternoon Night Bed ( 약이름 ) ( 복용용량 ) ( 아침 ) ( 점심 ) ( 저녁 ) ( 취침시간 ) 본인 ( 부모 / 보호자 ) 은본인의자녀 ( 참가자 ) 가 2017년 6월 29일부터 2017년 7월 1일까지 2박 3일동안 Bakersfield Marriott Hotel 에서열리는 2017년사랑의캠프 에참석하기를허락합니다. 밀알선교단사랑의캠프에참석하여위급상황이발생할경우밀알선교단교사 / 간사 / 자원봉사자가응급처치를취할것도허락하며필요할경우 911 에신고하여 Emergency 로데리고가는것을허락합니다. 아울러본인자녀의부주의로생긴사고나혹다른어떤사고가생긴다고할지라도남가주밀알선교단에책임을묻지않겠습니다. I,, (parent/guardian) hereby give permission for my son/daughter, (participant) to attend 2017 Camp AGAPE from June 29 th July 1 st, 2017 held at Bakersfield Marriott Hotel provided by Milal Mission. I hereby give teachers and/or staff permission to treat and transport by car or ambulance to a doctor or emergency center for treatment, if deemed necessary by staff members of Milal Mission. Furthermore, I agree to release Milal Mission and Staff from any liability for any accidents and/or fees accrued. CA-PCamp-17-5
Camp AGAPE Parental Consent of Media Post Name (Korean/ 한글 ): Name (English/ 영어 ): 본인 ( 부모 / 보호자 ) 은본인의자녀 ( 참가자 ) 이밀알선교단부속 사랑의캠프에서활동하는사진 / 동영상촬영을허락하며필요시사진 / 동영상관련된미디어에게시함도허락합니다. I, (Parent / Guardian), hereby give permission to Milal Mission Camp AGAPE staff to take photos/videos of my son and/or daughter (participant) and/or myself and to post them to related media if it is necessary. Camp AGAPE Parental Consent of Transportation 본인 ( 부모 / 보호자 ) 은본인의자녀 ( 참가자 ) 밀알선교단부속사랑의캠프에서활동시차량이동 service를이용할것을허락합니다. 이동시사고가났을때남가주밀알선교단교사, 간사, 또는스텝에게책임을묻지않겠습니다. 허락하지않을시사랑의캠프장소로부모 / 보호자가라이드를제공해주셔야합니다. I, (Parent / Guardian), hereby give permission to Milal Mission Camp AGAPE staff to provide transportation for my son and/or daughter (participant) and agree to release them from any liability for any accidents that may occur. Please be advised that if you do not give transportation consent, you will be required to provide transportation to and from the location of Camp AGAPE. CA-PCamp-17-6