Kigali/BugeseraMedical&PermissionSlipGLOW.doc (camp-glow-rwanda@googlegroups.com)

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Here is the Kigali/Bugesera's liability/medical/permission form, as promised.  If you just edit the dates and location, it should be a one-size fits all.  Thanks for the instructions on loading documents, Keira!

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• Kigali/BugeseraMedical&PermissionSlipGLOW.doc

Peace Corps Camp GLOW 2011

Permission Slip & Medical Information

The Kigali-Bugesera Camp GLOW will take place from November 28 – December 2 at GS Rango School in Ruhuha, Bugesera district.  The camp will include young women from local secondary schools and will be facilitated by local men and women and Peace Corps Volunteers from the United States.  Participants will be involved in English-language discussions and activities, focusing on topics like self-esteem, relationships, decision-making, leadership, and HIV-prevention.  Outdoor activities, campfires, a talent show, and artistic activities will also be important parts of the camp.

All participants have agreed not to smoke, drink alcohol, or use illegal drugs during camp.  Any participants who smoke, drink, or use drugs will be sent home.  We have asked participants to secure their place by making a deposit of 2,000 rwf.  This deposit will be refunded at the end of the camp, as long as the participant has followed the above agreement.

All participants must also bring a health insurance card—either Mutuelle or Rama—to Camp GLOW.  Participants cannot attend Camp GLOW without one.

Participant’s name: ___________________________________________

Parent’s/Guardian’s name: ________________________________________

Relationship to camp participant: _________________________________

Address: __________________________________________

Phone number: _____________________________________

Second contact: _______________________________________________

Relationship to camp participant: __________________________________

Phone number: _____________________________________________

Please list any allergies that the participant has:

Please list any medication that the participant will be bringing to the camp:

I understand the nature of Camp GLOW 2011 and that my daughter will be attending.

                                        ____________________________

                                                Guardian’s signature

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