Dharma Camp Application and Registration Form The dates for Dharma Camp 2013 are July 14-20.

See a printable version of this form (pdf). Download Adobe Acrobat to read pdf's.

Mandala on the Mountain

Application for Dharma Camp 2013

Note: Filling out this form does not guarantee a space in Dharma Camp. However, every student attending must have submitted this form before being accepted. Priority will be given to those who have registration forms in early and to those who regularly attend Dharma Rain Zen Center or Zen Community of Oregon programs.

Click here to register for Dharma School 2012-2013.

Youth’s Name

Youth’s Birthdate Gender
Grade (entering)
Shirt Size xsm sm m lg xlg

Parent/Guardian’s Name(s)

E-mail address
Phone

Street Address
City State Zip

Current Dues-Paying Member DRZC ZCO Non-member

For student to fill out (please answer yes or no):
I understand that this is a Buddhist program for kids and I want to have some fun while learning to do Buddhist practice. Yes No
I have been learning about Buddhism at home or at a temple. Yes No
I attend Dharma School at Dharma Rain or Great Vow regularly. Yes No

Emergency Information

In case of emergency, please notify:

Name
Phone Relationship
Alternate
Phone Relationship

Does the youth have medical insurance coverage? Yes No

Name of Primary Care Physician
Phone
Name of Provider
Plan
account #

Does the youth have dental insurance coverage? Yes No

Name of Dentist
Phone
Name of Provider
Plan
account #

Health History

Please answer Yes or No for each of the following:

Does the young person have a medical or mental health condition that a doctor or medical professional should be informed of in case of an emergency?
Yes No
If yes, please describe:

Drug allergy? Yes No
If yes, please describe:

Food allergy? Yes No
If yes, please describe:

Chronic or recurring illness? Yes No
If yes, please describe:

Does this young person have all the immunizations up to date?
Yes No If NO, please describe:

Need to take regular medication? Yes No
If yes, please describe:

Behavioral disorders? Yes No
If yes, please describe:

Other? Please describe any special concerns you have about the youth’s comfort and what might interfere with the success of an overnight or camp experience. We would appreciate some insight into the strength, weakness, and/or idiosyncrasies of the young person’s character and physical being that might help us interact well and guide effectively.

Release Form

Please answer Yes or No to each statement.

Youth may be given regular over-the-counter medications such as aspirin, Tylenol, or cough medicine by the camp staff while at a Dharma School activity or at Mandala on the Mountain. Yes No
Are there any over-the-counter or topical medications that should NOT be given to the child?

Youth has prescription medication that should be self-administered as per physician’s directions. Yes No
Please list medications and describe administration:

Youth has prescription medication that should be administered by adult staff member as per directions on medicine bottle. Yes No
Please list medications and directions for administration:

Youth may be given any and all medical treatment deemed proper and necessary by an attending physician in case of emergency. Yes No

I understand that photographs and videos may be taken at Dharma School or Dharma Camp. I hereby give permission for the use of such images of my youth to be used for the promotion of Mandala on the Mountain, Dharma Rain Zen Center, or Dharma School. I understand that children are never identified by name in publications, unless by express permission of the parent(s) (and child if old enough to object). See the DRZC Photo and Video Policy for further information. Yes No

I have filled out this form fully and accurately to the best of my knowledge. I agree to release Northwest Zen Sangha, Dharma Rain Zen Center, Great Vow Zen Monastery and the staff of the Dharma School and Mandala on the Mountain Dharma Camp from any liabilities that might accrue from reasonable and normal activities during the time my child in their care. My questions about Dharma Camp, Dharma School, and overnight participation have been satisfactorily answered.

Name of Parent filling out this form
Date

 

Back to Dharma Camp Information Dharma School information 

Pay for Camp (if “Submit” button doesn’t work)

Pay for Dharma School registration