Tribalyouthprogram.org

INDIAN VILLAGE CAMP PERMISSION FORMS
Check-in for Indian Village Camp is between 10 a.m. and 12 noon on the first day of camp. RISK ADVISORY

Parents, guardians, and potential participants in Indian Village Camp are advised that journeying
to and from the Indian Village Camp, and one’s participation in the Indian Village Camp
program, can involve exposure to accident, illness, and/or injury associated with exposure to the
elements, physically demanding, high adventure program in a remote wilderness area. Campers
may be exposed to occasional severe weather conditions such as lightning, hail, flash floods and
heat. Other potential accidents include: injuries from tripping and falling, motor vehicle
accidents, asthma and diabetes related accidents, heart attacks, heat exhaustion, and falls.
Participant’s Name: _______________________________________________________
Birth Date: ___________ SEX: _____________
Participant Signature______________________________________________________
Parent’s/Guardian’s Name_________________________________________________
Phone # (W) ______________________ (H) __________________________
Parent’s/Guardian’s Signature______________________________________________
Conditions of Admission (Court Order, Probation, Parental Agreement, Diversion, or
Other)_________________________________________________________________
Coordinating agency and/or case manager_____________________________________
Health Insurance Co. _______________________________________
Policy # _________________________________________________
Policy Holder__________________________________________________________________
Name of Physician______________________________________________________________
Physician Address _________________________City _______________ Zip Code _________
Emergency Contact Names ________________________________________
Phone # _______________________________________________________
Special Note on Medications: If your camper carries an “EPI” pen or inhaler we will require that
two are available during program.

Parent/Guardian signature:
________________________________________________________ DATE: ______________
Diet and Nutrition:
This camper eats a regular diet: Yes No
This camper eats a vegetarian diet: Yes No
This camper has special food needs or allergies? Yes No (If yes, please describe below)
_____________________________________________________________________________

Medications:
This camper will not take any daily medications while attending camp.________
This camper will take the following daily medication (s) while at camp:
_____________________________________________________________________________
Medication is any substance a person takes to maintain and/or improve their health. This
includes vitamins herbs and other natural remedies. We require original pharmacy containers
with labels which show the camper’s name and how medication is to be given.

Provide:
the name of medication_________________________ the date started_____________________
the reason for taking the medication_________________________________________________
when it is to be given________________ the amount or dose given________________________
how it is administered_______________ Other _______________________________________
Indian Village Camp will only administer medication to participants if:
1. The Permission to Administer Physician Prescribed Medication Form is completed and in the possession of Indian Village Camp. 2. The pharmacist or physician’s label, which must be on the bottle, will serve as the 3. It is in a container dispensed by a pharmacy with the participant’s name, name of medication, the date the prescription was filled and with the DIRECTIONS and DOSAGES CLEARLY MARKED. 4. Parents transport medication to Indian Village Camp Site and give directly to staff. 5. Parents know that medications will not be stored after completion of the program and that medication left on site at Indian Village Camp will be destroyed. I, the undersigned, have read and understand this entire form. This health history of the applicant is accurate and complete and the person herein described has my permission to engage in all Indian Village Camp activities described, except as specifically noted on this form. If I cannot be reached in an emergency, I hereby give permission for medical personnel, or the adult advisor in charge, to treat, hospitalize, secure anesthesia or to order injection, surgery or other treatment for the person described herein. While the youth participant is at Indian Village Camp, the Camp is authorized, with my permission, to obtain all information connected with treatment by a physician, hospital, or other treatment facility. Parent or Guardian signature: _______________________________________________________Date__________________ General Health History:
Height ________Weight ______ Pulse _________ BP _________Date of Exam____________
History of Hospitalizations: ______________________________________________________
Major Surgery ______________________Major/chronic/recurring illness _________________
Recent infectious disease _______________________Recent Injury ______________________
Vision Problems/Eyeglasses/Contacts ___________ Hearing Problems ____________________
History of Sprains, Fractures, Dislocations __________________________________________
Back or Joint Problems __________________________________________________________
Impaired Motor Activity ________________Concussion or Head Injury ___________________
History of Fainting or dizziness ___________________________________________________
Problems from physical exertion __________________________________________________
Heat Stroke/Exhaustion ________________________________________________________

Allergies:
Medicine _____________________ Foods ___________________________
Insects ______________________ Plants ___________________________
Environmental ________________ Other ____________________________
Headaches ___________________________ Seizures/Epilepsy __________________________
Asthma or shortness of breath _____________________________________________________
Diabetes ______________________________________________________________________
Heart Disease/Defect ____________________________________________________________
Sleep Problems _________________________ Diarrhea/constipation______________________
Pertinent Mental Health Issues or History:____________________________________________
OTHER:______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please give detailed information for anything described above, including symptoms, frequency,
type, trigger mechanism and history of occurrence (use additional pages if necessary). Please
note if this will pose a problem to participation in Indian Village Camp.
Social Health History:
Please describe and disclose any emotional or behavioral difficulties, eating disorders, suicide
attempts, acts of violence or aggression, recent deaths or family related disruptions or any other
significant life changing event that may continue to affect the participant, any history of self
abuse, any history of physical or sexual abuse, is the participant the survivor of a disaster or
other traumatic event, list any services that you may know of that have been provided to address
any mental/emotional or any other health concerns that may not have been mentioned.
Please give detailed information for anything mentioned above.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Parent/Guardian signature:
________________________________________________________ DATE: ______________

Non-prescription Medications Consent
Indian Village Camp carries a selection of non-prescription medications in our wilderness first
aid kits. We only provide these medications when an obvious, acute need exists, and campers do
not have access to them without approval from staff. By signing this form, you give your
permission for our staff to administer these medications to your child. Circle the medication that
you give consent to administer.
Acetaminophen
(Tylenol) Pain reliever, fever reducer
Ibuprofen (Advil) Pain reliever, anti-inflammatory
Bismuth-Subsalicylate (Kaopectate)
Diarrhea relief
Dramamine/Bonine
Diphenhydramine
antihistamine(Benadryl)
Other:_______________________________________
This registrant will be participating in an active and sometimes stressful program of outdoor
activities that include wilderness survival instruction and other rigorous and often remote
adventure activities. Disability may limit his/her activities, but not necessarily prevent
participation.

I, the undersigned, have read and understand this entire form. This health history of the applicant
is accurate and complete, and the person herein described has my permission to engage in all
Indian Village Camp activities, except as specifically noted on this form.
Parent/Guardian signature:
________________________________________________________ DATE: ______________


RELEASE OF LIABILITY AGREEMENT, WAIVER OF CLAIMS, ASSUMPTION OF RISK AND
INDEMNITY AGREEMENT: Minor Permission Form
Additional Consent to Participate in the Little River Band of Ottawa Indians Indian Village Camp and
Release of Liability
By signing below, I request that my Child/Teenager, who is 17 years old or younger be permitted
to participate in the Indian Village Camp activities which include certain risks, including those
described in the Release, Waiver of Liability and Indemnification Agreement (incorporated
herein) signed by my Child and of which I acknowledge I have read fully and understand and
agree with the complete content of such Agreement. I have discussed the risks of participation
and directed the participant to abide by all rules, guidelines and instruction provided by the
Indian Village Camp and its staff. I consent to my Child’s/Teenager’s participation in the Indian
Village Camp activity. I further provide permission to Indian Village Camp and/or Little River
Band of Ottawa Indians representatives to seek medical treatment for the participant, and to
provide health and other information as needed. I understand that this participant takes part in the
Indian Village Camp activity at his/her sole risk, and that I assume full responsibility for any
injury, loss or damages incurred by my Child/Teenager or by any other person in connection
with my Child’s/Teenager’s participation in the Indian Village Camp activity. As such, I agree to
forever Release, Indemnify, Discharge and Hold Harmless the Little River Band of Ottawa
Indians, Indian Village Camp and each of their respective representatives from any and all
liability, claims, damages, costs, expenses loss and causes of actions that in anyway and anytime
arise out of this participants involvement with the Indian Village Camp. As with most rustic or
wilderness recreational activities, Participant acknowledges and understands that involvement in
the activities of the Indian Village Camp are not without risk. Such risks of participation in the
Indian Village Camp include but certainly are not limited to, loss or damage to personal
property, injury or death of Participant. Recognizing such events and damages as being possible,
the parent/guardian and the Participant understand that property damage or injuries to
Participant may be substantial and permanent. Parent/Guardian acknowledges that these are just
some of the known risks and that other risks, both known and unknown are involved in this rustic
wilderness activity. If, at any time, Participant feels anything to be unsafe, the Participant agrees
to immediately advise Indian Village Camp personnel who will determine whether or not the
complaint is valid and should be corrected. Participant understands the strenuous nature, both
emotionally and physically, of this activity, and the Participant has no medical or physical
condition which could interfere with the safety of the Participant or other participants in the
Indian Village Camp. As such, Participant warrants that Participant is physically and mentally
capable of safely participating in all aspects of the Indian Village Camp activity. Participant
agrees to abide by all rules, guidelines and instruction established by Indian Village Camp. The
failure to abide by all such rules, guidelines and/or instructions of Indian Village Camp may
result in withdrawing permission of Participant to remain in the Indian Village Camp program.
Participant expressly accepts full responsibility and risk of bodily injury, death or property
damage. Participant and parent/guardian is of sound mind to enter into this legally binding
Agreement.
I HAVE READ THIS ENTIRE DOCUMENT AND COMPLETELY UNDERSTAND THE
TERMS AND CONDITIONS. THIS IS A LEGALLY BINDING CONTRACT.

Parent/Guardian signature:
________________________________________________________ DATE: ______________

Participant’s Name_______________________________________________________
Participant Signature__________________________________ Date _______________
Participant’s Birth date: ________/__________/__________
Mo. Day Year
Parent’s/Guardian’s Name_________________________________________________
Parent’s/Guardian’s Signature_________________________ Date _______________

Address: ________________________________________________________________
City: ______________________________________ State: _____________
Zip Code: ___________Birth date: ______/_____/______
E-Mail: __________________________________________

MINORS

PERMISSION TO USE PHOTOGRAPHIC OR VIDEO IMAGE OF MINOR (Under 18 years
of age) FOR THE PROMOTION AND/OR DOCUMENTATION OF INDIAN VILLAGE
CAMP PROGRAM.
I give permission to allow the use of a photograph or video image of a youth to the Little River
Band of Ottawa Indians to use as part of Indian Village Camp program promotion and
documentation. I am this youth’s legal parent or guardian and have the right to legally release
this right to use a photograph or video image.
Name of youth____________________________________________________
Signature of parent or legal guardian__________________________________
Date____________________________________________________________

ADULTS

PERMISSION TO USE PHOTOGRAPHIC OR VIDEO IMAGE FOR THE PROMOTION
AND/OR DOCUMENTATION OF INDIAN VILLAGE CAMP PROGRAM.
I give permission to allow the use my photograph or video image to the Little River Band of
Ottawa Indians, to use as part of Indian Village Camp program promotion and documentation. I
am 18 years of age or older and have the right to legally release my image to use as a
photograph or video.
Name of adult releasing image use rights_____________________________________________
Signature
______________________________________________________________________
Date__________________________________________________________________________
WHAT TO BRING TO CAMP

Suggested Personal Equipment: (If someone does not have, or forgets to bring vital equipment, we will
provide, if possible.)
• Soap
• Hat (Mark all of your equipment with your name and phone number.) WHAT NOT TO BRING TO CAMP:
Knives , Extra food or snacks, Fireworks, Matches or Lighters, Personal Firearms, Weapons, Ammunition, Martial Arts Equipment, Pets, Any kind of electronic device, Radios, TV's, Video Games, or Tape Players, Pornographic or sexually related materials, Non-participant Siblings, Electronic Games, Walkmans or Discmans, mp3’s, Alcohol, a bad attitude. Directions to Indian Village:
From Brethren MI.
Take High Bridge Rd. 2.5 miles to the South. There will be a slight curve to the left. (On that
curve is River Rd.) Take a right on River Road, heading West for 2.25 miles. Indian Village Rd
will be on your left, heading South. Take Indian Village Rd. (On the corner of River Rd. and
Indian Village Rd is a house with a large blue and white pole barn.) Indian Village Road dead
ends in ½ mile right at Indian Village Camp.
From HWY M-55
If you are coming from Cadillac or Manistee by travelling down M-55, you will take High
Bridge Rd (High bridge Rd. is about 2 ¾ miles West of Wellston.) Take High bridge to the North
for 3 ½ miles. (You will cross the Manistee River. ) Turn left, or West, on River Rd. Stay on
River Rd. for 2.25 miles. Indian Village Rd. will be on your left, heading South. Take Indian
Village Rd. (On the corner of River Rd. and Indian Village Rd is a house with a large blue and
white pole barn.) Indian Village Road dead ends in ½ mile right at Indian Village Camp.
FROM HWY M-31 (From Manistee)
M-22 and M-31 intersect at the Little River Casino just North of Manistee. 2 ¾ miles North of
this intersection, on M-31, there is a road that heads East called Coates Highway. Take Coates
HWY East for 1 mile and then turn right (South) on Milarch Rd. (There is a sign with an arrow
indication “Big Manistee River”) Go ½ mile on Milarch and then turn left (East) on River Rd.
Take River Rd. for 7 miles. (You will pass Rainbow Bend and then pass where Bear Creek meets
the Big Manistee River). You will go through several curves. Indian Village Rd. will be on your
right, heading South. Take Indian Village Rd. (On the corner of River Rd. and Indian Village Rd
is a house with a large blue and white pole barn.) Indian Village Road dead ends in ½ mile right
at Indian Village Camp.
FROM HWY M-31 (From the North)
(Very few people should need to come from this way unless they are coming from Benzie or
Leelanau Counties. If you are coming from anywhere North or East of Traverse City then find
Brethren and use those directions.) M-31 goes through Bear Lake. Continue on M-31 for 7.5
miles and turn left on Milarch Rd. You will be travelling South. In 1 mile you will come to a stop
sign. Cross Coates HWY at the stop sign, continuing for another ½ mile on Milarch Rd. to River
Rd. You will turn left (or East) on River Rd. Take River Rd. for 7 miles. (You will pass Rainbow
Bend and then pass where Bear Creek meets the Big Manistee River). You will go through
several curves. Indian Village Rd. will be on your right, heading South. Take Indian Village Rd.
(On the corner of River Rd. and Indian Village Rd is a house with a large blue and white pole
barn.) Indian Village Road dead ends in ½ mile right at Indian Village Camp.
Tribal Receptionist 231-723-8288, Austen Brauker 231-398-2240, Pat Wilson 231-398-2239
Tribal Court 231-398-2223 or 231-398-2235, Court Administrator 231-398-2236

Source: http://www.tribalyouthprogram.org/sites/tribalyouthprogram.org/files/INDIAN%20VILLAGE%20CAMP%20ALL%20FORMS.pdf