WHAT IS CAMP BLUEBIRD?

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1 WHAT IS CAMP BLUEBIRD? Camp Bluebird is not an ordinary camp. It is a wonderful retreat for cancer survivors, patients, and counselors. Camp Bluebird has brought joy, value, and encouragement to many cancer patients as well as great pleasure to health professionals who supervise the camp. The adult retreat is designed for campers to get away and take part in a number of activities such as: Sharing and Caring, Arts and Crafts, Rest and Relaxation, Fun and Games, Strolls to the Lake, and Nature Walks WHO MAY ATTEND CAMP BLUEBIRD? Any adult (age 18 and over) who has had a cancer diagnosis, either current or in the past WHERE IS CAMP BLUEBIRD? Camp Bluebird will be held at St. Bernard Retreat & Conference Center on the campus of St. Bernard Abbey, a monastery of Catholic Benedictine Monks, in Cullman, AL. The Retreat Center is surrounded by 800 wooded acres and Eight Mile Creek. The scenic trails, lawns and lakes nestled in a treasure forest provide a peaceful setting for Camp Bluebird. The St. Bernard campus is also home to the world famous Ave Maria Grotto and the Monastery candle shop. WHAT ARE THE ACCOMODATIONS LIKE? St. Bernard Abbey Retreat Center is a newly renovated facility with modern meeting rooms for large and small groups. The facility also has a dining hall and hotel-style rooms furnished with two beds and a private bathroom. HOW DO I APPLY? Complete the attached application form and return by September 24. You will be notified by mail no later than October 18, 2010, of the status of your application. WHAT IS THE COST OF THE CAMP? The camp is free to campers. Camp Bluebird is a special project of St. Vincent s East, St. Vincent s East Foundation and the St. Vincent s East Auxiliary.

2 All Information must be complete or application will not be accepted. PERSONAL INFORMATION: Date: RETURN TO: Beth Caine STVE CAMP BLUEBIRD 44 Medical Park East Drive Birmingham, AL Fax: Last Name: First Name: Address: City: State: Zip Code: Date of Birth: Daytime Phone: Evening Phone: 1. Have you ever attended a St. Vincent s East - sponsored Camp Bluebird? Yes No 2. Cancer Diagnosis: Diagnosis Date: 3. Are you currently receiving any type of cancer treatment? Yes No If yes, what type of treatment are you receiving? Radiation Therapy Chemotherapy Pill Shot

3 PHYSICIAN INFORMATION: 1. Name of your personal doctor: Office phone number: 2. Name of your cancer doctor, if any: Office phone number: IN ORDER TO ATTEND CAMP, WE MUST HAVE PERMISSION TO CONTACT YOUR DOCTOR(S) IN THE EVENT OF AN EMERGENCY. (your signature) INSURANCE: Insurance Provider: Policy Number: Policy Holder: Insurance Provider: Policy Number: Policy Holder: EMERGENCY CONTACTS: 1. Name a. Relationship to you b. Home phone c. Cell phone or other phone 2. Name a. Relationship to you b. Home phone c. Cell phone

4 SPECIAL NEEDS: Assistance with medicines Oxygen Wheelchair Room with handicapped shower Known allergies (LIST ANY TO FOOD, MEDICINES, BEES, ETC.) 1. Do you need a ride from St. Vincent s East to camp and back? yes no 2. T-shirt size: S M L XL XXL XXXL 3. Current medications: (list name, strength, dose) Use back or enclose a separate medical list if necessary. Medication Name Strength Dose - How often do you take this medication?

5 PLEASE READ AND SIGN THE FOLLOWING: I hereby release and hold harmless St. Vincent s Health System (STVHS) and its agents, investors, owners, insurance carriers, divisions, employees, volunteers, partners, shareholders, officers, directors, agents, successors, affiliates and assigns, whether previously or hereafter affiliated in any manner with STVHS, from any and all actions, causes of action, claims, damages or loss of services or expenses related to any injury or liability, whether actual, exemplary or punitive, caused by my participation in Camp Bluebird. Said release of STVHS extends to liabilities of any nature, whether or not now known, suspected or claimed, arising directly or indirectly from my participation. I further agree to indemnify STVHS and all its partners, shareholders, officers, directors, agents, employees, successors, affiliates and assigns from and against any and all claims, demands, damages and causes of action related to or arising out of my attendance through any negligent conduct on my part. This indemnification shall include any costs or attorney s fees associated with enforcing this release. I understand, acknowledge and agree that my participation in this event is strictly voluntary and that I do not serve in any capacity as an agent of STVHS or any of its subsidiaries, employees or affiliates. Signature Date Consent for Photograph Release Initial Initial YES I authorize St. Vincent s East to photograph me and to display my picture and my name for purposes of education as it relates to the Cancer Program or other Cancer Support Services events such as Camp Bluebird. NO I do not authorize St. Vincent s East to photograph me or to display my name for purposes of education as it relates to the Cancer Program or other Cancer Support Services events such as Camp Bluebird Patient Name Witness Signature Patient Signature Date