Operation Purple Summer Camp: A free summer camp for military kids ages 10-15.

1. FREE SUMMER CAMP
FOR MILITARY KIDS
The National Military Family
Association’s Operation Purple®
camps offer a free week of fun
for military kids with parents SIGN UP TO ATTEND
who have been, are currently, THE CAMP IN YOUR AREA.
or will be deployed.
Visit www.MilitaryFamily.org
Camp Location: Dates: for registration information, locations, and dates.
4-H Rural Life Center August 1 - 7, 2010
Halifax, NC Ages While At Camp:
Ages 10 - 15 Co-ed
®
A program of the National Military Family Association

2. Operation Purple® Camp
The 4-H Rural Life Center is located in rural Halifax, North Carolina where
the “Spirit of Independence Was Born” at 13763 Highway 903. The 4-H Center
was originally built as the county home around 1923, but was taken over by the
Halifax County Cooperative Extension Service around 1985 and turned into the
4-H Camp. This was a perfect fit as the dormitory building laid out exactly the
way a camp needed with a wing for boys and a wing for girls with a common
area, dining room, and kitchen between. Each wing has small individual rooms
with two to four bunk beds as well as two bathrooms. The heated and air
conditioned facilities makes summer camp very comfortable for a home away
from home. Our facility is located on over 345 acres and has many amenities
which include the main camp building, a Rosenwald School, an antique
agricultural equipment museum, an outside basketball court, volleyball court, and
soccer / softball field. We also have an archery range, a high and low ropes
course, and a climbing wall along with many hiking trails and ten canoes for use
with some of our field trips.
This year the 4-H Rural Life Center in partnership with the National Military
Family Association, Inc. will be offering a residential Operation Purple® Camp
to children of military families. Deployment affects everyone in the family, not
just the service member. Here at camp, we feel the real heroes are the children
as we feel “kids serve too” and we are proud and honored to offer a week of
camp to this extremely special group of campers. This is going to be a week you
do not want to miss.
The following information should help you with some of the questions you
may have as well as let you know what we will be accomplishing this week. At
the end of this is the Operation Purple® Camper Summer Camp Application
which you will need to fill out and sign and mail back in to us here at the 4-H
Rural Life Center. For more information you can contact us here at the 4-H
Center at 252-583-1821 or call the Cooperative Extension Service at 252-583-
5161. Our mailing address is as follows: 4-H Rural Life Center - P.O. Box 37
- Halifax, NC 27839 and we are located at physical address for shipping:
13763 Hwy. 903 - Halifax, NC 27839. Mail or packages may be sent to these
addresses for campers, but we do not have email available for camper use.
Please remember it takes time for mail to arrive here. The telephone is for
emergency uses only.

3. General Information
Arrival / Departure
Check in for camp will be from 4:00 pm until 5:00 pm on Sunday, August 1, 2010.
Please do not arrive early as the counselors will be in the process of making sure
things are ready for your arrival prior to this time. If you need to arrive at a
different time, please call and let us know what arrangements need to be made
Monday through Friday from 9:00 am until 4:00 pm. Departure will be at 9:00 am
on Saturday, August 7, 2010. It is important to adhere to this schedule.
Dinner will be served to campers on Sunday evening after check in.
Cost
This camp is provided free of charge to all eligible participants and will be paid in
full by the National Military Family Association, Inc. Operation Purple Camp.
What to Bring to Camp
Fitted and Flat Sheet with Blanket for Single Size Bed or a Sleeping Bag
Pillow with Pillowcase
5 to 6 Towels and Washcloths
Toiletries (Toothbrush, Toothpaste, Soap, Deodorant, Shampoo, etc.)
2 to 3 Swimsuits
Plenty of Appropriate Summer Clothing (T-shirts, Long and Short Pants, Jacket)
1 Pair of Old Shoes or Water Shoes
Tennis Shoes
Rain Gear
Insect Repellant
Sunscreen
Camera (Optional)
Spending Money (Just for Souvenirs While on Field Trips – No More than $25)
(Campers will be responsible for their own spending money as all meals
and tickets will be paid for already.)
What Not to Bring to Camp
Excessive Amounts of Money
Excessive Food, Drinks, and Snacks (Snacks will be Provided)
Radios, Televisions, Stereos, Cell Phones, etc.
No Expensive Items, Especially Jewelry
No Weapons or Controlled Substances of Any Kind
(Campers will be responsible for what they bring and neither the 4-H Rural
Life Center nor the staff will be responsible for any losses.)
Room Assignments While At Camp
Each room has either two or four single size bunk beds. We will make room
assignments as campers arrive and will try to accommodate any request possible
for roommates. This is also something that can change during the week at the
camper’s requests, or as needed by staff if curfews are not adhered to at night.
Please attach a note to the application to let us know if you have a roommate
preference ahead of time. Also, if coming with siblings of the same gender,
attach a note to let us know if you would like to share a room with them or not.

4. This Week’s Schedule of Activities:
Our goal is to make this week the most meaningful and memorable
adventure that our campers ever have. We would like for them to come away
from camp learning many new skills, making new friends, learning something
about military life, and having had the most fun possible. In order to accomplish
these goals, we have planned a wide variety of activities and field trips that all
campers should find enjoyable.
As for our field trips, we will be going to Water Country, USA in
Williamsburg, VA for a day at the water park and possibly visit Fort Eustis as
well. Campers will enjoy giant slides, lazy rivers, water tubes, and many other
activities while at Water Country. Lifeguards will be on duty and knowing how to
swim is not required. We also plan to take another day long field trip to the NC
Zoological Park in Asheboro, NC. Here campers will be able to learn about many
different animal species and see them in their natural habitats as they range in
open prairies in environments similar to the continent they actually come from.
Both of these trips are around two hours from camp and we will go and come on
air conditioned charter buses with bathrooms.
We may also take some local field trips which may include a visit into
Historic Halifax where campers will be able to tour a period in time from the
1700’s. Halifax, NC is where the Halifax Resolves was signed on April 12, 1776
which made NC the first of the 13 English Colonies to declare it’s independence
from Great Britain which led to the signing of the Declaration of Independence for
the United States from England on July 4, 1776. We also plan to visit our local
aquatic center where campers will have the opportunity to spend time swimming
and learning about aquatics. If time permits, we may also take a field trip to Lake
Gaston where we may have the opportunity to canoe and possibly even try our
hand at fishing. We may even do some bowling one day and possibly go to a
local theater for a private showing of a movie or show. Any movies we see will
be rated either G, PG, or PG-13.
Other activities this week may include crafts, camp songs, astronomy,
sports, team building through the use of our challenge courses and climbing wall,
camp fires, cookouts, and many military opportunities to see how the camper’s
family members work and function each day. As the military will be a big part of
our camp, we expect to have lots of activities geared towards this way of life. It
will be difficult to list these different activities as things can change right up to the
last minute with the military depending on their status at any given time.
Parachute jumpers, flyovers, rides in hummers and tanks are all possible
activities along with many others. We will also participate in a community service
project to learn how we can all give back to society no matter what age.
Normally, we should begin our day by rising around 7:00 am and having
breakfast around 8:00 am. Daily activities should begin by 9:00 am with lunch
around noon and dinner around 6:00 pm. Evening activities will conclude most
evenings by 10:00 pm with lights out by 10:30 pm. Showers will usually be taken
in the evenings prior to bedtime. We will also take time each evening to reflect
on the day and talk about anything the campers feels are important to them, and
do some journaling. This schedule is certainly going to be flexible and may
change as we have many activities scheduled for every day of this week.
By the end of this week, campers will have made new friends, learned
many new skills, and discovered many new aspects of military life they never
new existed and should leave camp with a fresh outlook letting them know they
are heroes because “kids serve too”.

5. 4-H Rural Life Center Attach
Photo
Here
Operation Purple® Camper Summer Camp Application
Camper Name____________________________________ Birth Date____________ Age at Camp_______ Gender____
Last First Middle
Home Address_____________________________________________________County_______________ Grade______
Street City State Zip
Nickname to be used at camp if different from above _____________________ Email Address _____________________
Parent or Guardian: ___________________________ Second Parent or Guardian: _____________________________
Address: ___________________________________ Address: ____________________________________________
_____________________________ ____________________________________
Home Phone / Cell / Work_______________________ Home Phone / Cell / Work______________________________
Emergency Contact (Other than Parent/Guardian) Name / Relationship_______________________________ Phone___________________
Health History
The following information must be filled in by the parent/guardian. Update required annually. Health exam must be
completed by approved licensed medical personnel within 12 months of participation. The intent of this information is to
provide camp health care personnel the background to provide appropriate care. Keep a copy of the completed form for
your records. Any changes to this form should be provided to camp health personnel upon participant’s arrival in camp.
Provide complete information so that the camp can be aware of your needs.
MEDICATIONS
Please list ALL medications, even over-the-counter or nonprescription drugs, including Tylenol, Pepto-Bismol, Benadryl, etc.
that may be taken. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that
identifies the prescribing physician (if prescription drug), the name of medication, the dosage, and the frequency of
administration. Please turn over all medications to the camp health personnel while attending camp.
This person takes NO medications on a routine basis
This person takes medications as follows:
Med#1_________________________ Reason _____________ Dosage__________ Time taken ______________
Med#2_________________________ Reason _____________ Dosage__________ Time taken ______________
Med#3_________________________ Reason _____________ Dosage__________ Time taken ______________
Med#4_________________________ Reason _____________ Dosage__________ Time taken ______________
This person may take the following medications as needed:
Aspirin Tylenol Ibuprofen Benadryl Pepto-Bismol Other_____________________
General Questions (Explain “yes” answers.)
Has/does the participant: Yes No Yes No
1. Had any recent injury, illness or infectious disease? 13. Ever had high blood pressure?
2. Have a chronic or recurring illness/condition? 14. Ever been diagnosed with a heart murmur?
3. Ever been hospitalized? 15. Ever had back problems?
4. Ever had surgery? 16. Ever had joint problems?
5. Have frequent headaches? 17. Have any skin problems?
6. Ever had a head injury? 18. Have diabetes?
7. Ever been knocked unconscious? 19. Have asthma?
8. Wear glasses, contacts or protective eye wear? 20. Had mononucleosis in the past 12 months?
9. Ever had frequent ear infections? 21. Have problems sleepwalking?
10. Ever been dizzy/passed out during or after exercise? 22. Have a history of bed wetting?
11. Ever had seizures 23. Ever had an eating disorder?
12. Ever had chest pain during or after exercise? 24. Ever been found to have any mental disorder?
Please explain “yes” answers, noting the number of the questions.
___________________________________________________________________________________________________________________________

6. Known allergies to foods, drugs, insect stings or bites, etc.: __________________________________________________
Special medical, mental, psychological, dietary or physical Family Physician Name: _________________________
concerns or restrictions: __________________________ Address:_________________ Telephone: ___________
Which of the following has the participant had? Please give dates of immunization for: (Attach Shot Record)
Vaccine: Dates: Mo/Yr Mo/Yr Mo/Yr Mo/Yr
Measles DTP ____ ____ ____ ____
Chicken pox
TD (tetanus/diphtheria) ____ ____ ____ ____
German measles
Tetanus ____ ____ ____ ____
Mumps
Polio ____ ____ ____ ____
Hepatitis A
MMR ____ ____
Hepatitis B
or Measles ____ ____
Hepatitis C
or Mumps ____ ____
TB Mantoux Test Date of last test________ or Rubella ____ ____
Result: Positive Negative Haemophilus influenza ____ ____ ____ ____
Family Dentist Name: ____________________________ Hepatitis B ____ ____ ____
Address:____________________Telephone:__________ Varicella (chicken pox) ____ ____ ____
Health Care Recommendations by Licensed Medical Personnel
I examined (camper name) _____________________ on _____________. BP_____ Wt _____ Ht______
In my opinion, the above applicant is is not able to participate in an active camp program and all activities.
Restrictions/Recommendations:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Signature of Licensed Medical Personnel _______________________________________________Date____________
Printed__________________________________________Title_______________________________________________
Address_________________________________________Phone_____________________________________________
Screening Record: For camp use only Date___________ Time_________
Meds received____________________________________________________________________________________
Updates/additions to Health History___________________________________________________________________
Current Health needs identified_______________________________________________________________________
Screened by____________________________
Custody Release: You may be asked to produce photo ID at check-out. This is for your child’s safety. Please be aware
of this policy before picking up your child. I hereby give permission for my child, _______________________________,
to be allowed to leave the 4-H Camp at the conclusion of the camping program. My child will be released into the custody
of _____________________________________________________________________________________________.
(Names of All Individuals authorized to pick up your child)
If it is necessary for my child to leave the Camp before the end of the program due to illness, injury, or behavioral issues,
and I can not be reached, I hereby give permission for my child to be released into the custody
of______________________________________________________________________________________________.
(Emergency contacts or other individuals authorized to pick up your child)
For Camp Use Only: Camper picked up by _____________________________ Staff Signature__________________.

7. In the event that the camper needs minor medical care from 4-H personnel or more significant medical care from a qualified
health care provider, including in rare cases possible hospitalization and or surgery, the parent / guardian is asked to read
and sign the informed consent form as follows:
I authorize the 4-H Rural Life Center personnel to do any acts which may be necessary or proper to provide for the health
care of the above named camper including, but not limited to, the power to provide for such health care at any hospital or
other institution, or the employing of any physician, dentist, nurse, or other person for such health care and to consent to and
authorize any health care, including administration of anesthesia, X-ray examination, performance of operations, and other
procedures by physicians, dentist, and other medical personnel except the withholding or withdrawal of life sustaining
procedures.
It may be necessary to bill the family’s insurance company. Please provide the following information:
Insurance Company: _________________________________
Address: _________________________________
_________________________________
Insurance Policy #: __________________________________
Telephone Number: __________________________________
Field Trip Permission – The above name camper has permission to go on any field trip(s) planned as part of the summer
4-H program.
Photograph Release – I, the undersigned, hereby authorize the 4-H Rural Life Center to use photographs, videos, or other
recordings which I have voluntarily allowed to be taken by representatives. I understand that such use may include, but
shall not be limited to, publications, slide shows, displays, or videos. I hereby waive any right to which I or my heirs may
otherwise be entitled by law to assert against the 4-H Center on account of injury sustained by my reputation arising from
causes of action including, but not limited to libel, slander, defamation of character and invasion of privacy as a result of
such publications and hereby release the 4-H Rural Life Center and it’s personnel from any liability on account of such
injury.
4-H Code of Conduct and Disciplinary Procedure – Please refer to the following internet link to obtain a copy and
understanding of this policy and have the camper sign below after reading it stating he / she agrees to be bound by it.
http://www.nc4h.org/centers/4hcodeofconduct.pdf
Camper’s Personal Property – Neither the 4-H Center nor the camp staff shall be responsible for the loss of or damage to
the personal property of the camper. Campers should not bring electronic devices or any other expensive items.
Damage – Parents will be responsible for and pay for any damage done by the camper either alone or with others.
No One is to leave camp without the prior permission of the Camp Director.
Telephone usage is for authorized emergencies only and should only be used with the permission of the Camp Director.
**Cell phones are not permitted at camp without prior permission of the Camp Director.**
I have read and understand this entire form and agree that to the best of my knowledge it is true and correct and to
be bound by all contained within.
Camper Name (Please Print): ___________________ STATE OF ________________, COUNTY OF _______________
Camper Signature: __________________ On this _________day of _________,20___, _______________,
Date: _______________ personally appeared before me the said named,____________,
to me known and known to me to be the person described in
Parent / Guardian Name (Please Print): ___________________ and who executed the foregoing instrument and he (or she)
Parent / Guardian Signature: _________________ acknowledged that he (or she) executed the same and being
Date: _______________ duly sworn by me, made oath that the statements in the
foregoing instrument are true.
My commission expires __________________,20____
____________________________________
(OFFICIAL SEAL) Notary Public
____________________________________
Please fill out completely and sign this application and mail it to: 4-H Rural Life Center
P.O. Box 37
Halifax, NC 27839
252-583-1821