PO Box 38 • Baraboo, WI 53913 - Habitat for Humanity ...

PO Box 38 • Baraboo, WI 53913 • (608) 448-2888 • www.hfhsca.org

Friday, February 28, 2014

To Whom It May Concern:

On Saturday, May 17 and Sunday, May 18, 2014
Habitat for Humanity of Sauk Columbia Area (HFHSCA) will
be hosting our annual Shanty Town at the Lodi Fairgrounds.
This is a major fundraising and awareness event for our local Habitat affiliate, and has been very
successful over the years involving our local youth, ages 12-18, who want to let the world know
they care about those living in substandard housing.

Now, it’s your turn to assemble a team to participate in building a home out of cardboard and
tape. At the Shanty Town, you will learn a lot, but also have fun while spending a night under the
stars! Not only will your team walk away with an understanding of poverty as it exists in our
community and around the world, but they will also enjoy games, activities, and food.

Participants dedicating their time, energy, creativity, and enthusiasm for this cause will be
rewarded with gratitude, prizes, and an event t-shirt.

Enclosed you will find team registration, a pledge form, a permission form, and a poster that we
encourage you to hang up to spread the word about this event. Please feel free to make additional
copies if needed. Please return team registration form and fees with permission slips by
Friday, April 25.

We encourage you to begin collecting cardboard boxes, tarps, tape, etc. now to make the best
shanty possible!

Since HFHSCA started in 2001, we’ve grown each and every year. We have now built 23
homes, and we also run a repair program that helps low-moderate income homeowners who
cannot afford repairs. Help us keep up this momentum! Put a roof over the heads of area
families!

If you have questions, please feel free to contact our office at (608) 448-2888 or via email:
[email protected].

Sincerely,

Joycelyn Fish
AmeriCorps VISTA
Habitat for Humanity of Sauk-Columbia Area

Shanty Town 2014
Team Registration

1211 8th Street • P.O. Box 38 • Baraboo, WI 53913 • Phone: (608) 448-2888 • Website: www.hfhsca.org

Habitat for Humanity® works to eliminate substandard housing and homelessness from our world. To support
that effort, Habitat for Humanity of Sauk-Columbia Area is hosting a Shantytown event. Let’s make this the
biggest Shanty Town event ever! Spend the night of May 17th at the Lodi Fairgrounds in a cardboard box under

the stars! Please return form, along with registration fee, by Friday, April 25!

Tentative Schedule:

Saturday, May 17 Registration, and set up shanty Sunday, May 18 Breakfast
2:30 – 4:45 p.m. Leader meeting 6:30 – 7:30 a.m. Worship service
Community Soup Supper Shanty breakdown & dismissal
4:45 p.m. Announcements and speaker 7:30 a.m.
5:00 – 6:00 p.m. Activities, games, and music
Lights out 9:15 a.m.
6:15 p.m.

7:30 p.m.

11:00 p.m.

All team members must be registered on this form; add additional team members’ names on back. Entry fee is
$60.00, which includes T-shirts for 5 team members. Please indicate T-shirt size (all adult sizes). Additional T-
shirts can be purchased for $10.00.

Team Name_______________________ Contact Phone No. __________________E-mail: ______________________

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

__________________________________________________________________________________________

Name Age T-Shirt Size Address Emergency Phone

Please return by

Friday, April 25! Shanty Town 2014: Medical/Permission Form

Participant Name ____________________________________________________________
Address ___________________________________________________________________
Home Phone ________________Email Address ___________________________________

Team Leader: ________________________________________________
The purpose of this form is to ensure consent from parents for participation in the Habitat for Humanity of
Sauk-Columbia Area (HFHSCA) Shantytown activities on May 17-18, 2014. It is also a form granting
permission for the treatment of minors who become ill or injured when the parents or guardians cannot be
reached to give consent for treatment. Every reasonable attempt will be made to contact the parent(s)/guardian
listed below.

Emergency Information: (Person to contact in case of emergency)

Name____________________________________________ Relation to Participant __________________
Phone Day___________________ Phone Eve______________________ Phone Other __________________
Address___________________________________________________________________________________
_________________________________________________________________________________________

Family Dr. Name ________________________________ Family Dr. Phone _______________________

Insurance Information: (please provide copy of insurance card)
Participant is covered by a medical insurance policy: Yes No
Insurance Company Name ________________________________________________________

Name of Policy Holder ___________________________________________________________

Group Policy Number ____________________________________________________________

Authorization Phone Number ______________________________________________________

Health History:
Allergies/special health concerns/needs: __________________________________________________
___________________________________________________________________________________
Medication(s) they can NOT take: _______________________________________________________
Medication(s) being taken: ____________________________________________________________
Special dietary needs: _________________________________________________________________
Any medical history that needs to be noted: ________________________________________________

Permission /Release/Authorization (for participants under 18)
I, the undersigned parent or guardian, do hereby grant permission for my child, _________________________,
to attend and participate in Habitat for Humanity Shanty Town 2014. I give the adult leaders permission to
provide basic aid to my child including the availability of basic over the counter medication including pain
reliever, antihistamine, etc.

I give the adult leaders permission to seek medical attention for my child even if they can not reach me or the
emergency contact. This may include treatment, administration of medicine, clinical procedures or surgery. I
understand that any fees would be the responsibility of me or my insurance company.

I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold
HFHSCA, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred
through participation in the HFHSCA programs.

______________________________________________________ __________________
Signature of Parent/Guardian Date

Please return by

Friday, April 25! Shanty Town 2014: Medical/Permission Form

Participant Name ____________________________________________________________
Address ___________________________________________________________________
Home Phone ________________Email Address ___________________________________

Team Leader: ________________________________________________
The purpose of this form is to ensure consent from parents for participation in the Habitat for Humanity of
Sauk-Columbia Area (HFHSCA) Shantytown activities on May 17-18, 2014. It is also a form granting
permission for the treatment of minors who become ill or injured when the parents or guardians cannot be
reached to give consent for treatment. Every reasonable attempt will be made to contact the parent(s)/guardian
listed below.

Emergency Information: (Person to contact in case of emergency)

Name____________________________________________ Relation to Participant __________________
Phone Day___________________ Phone Eve______________________ Phone Other __________________
Address___________________________________________________________________________________
_________________________________________________________________________________________

Family Dr. Name ________________________________ Family Dr. Phone _______________________

Insurance Information: (please provide copy of insurance card)
Participant is covered by a medical insurance policy: Yes No
Insurance Company Name ________________________________________________________

Name of Policy Holder ___________________________________________________________

Group Policy Number ____________________________________________________________

Authorization Phone Number ______________________________________________________

Health History:
Allergies/special health concerns/needs: __________________________________________________
___________________________________________________________________________________
Medication(s) they can NOT take: _______________________________________________________
Medication(s) being taken: ____________________________________________________________
Special dietary needs: _________________________________________________________________
Any medical history that needs to be noted: ________________________________________________

Permission /Release/Authorization (for participants under 18)
I, the undersigned parent or guardian, do hereby grant permission for my child, _________________________,
to attend and participate in Habitat for Humanity Shanty Town 2014. I give the adult leaders permission to
provide basic aid to my child including the availability of basic over the counter medication including pain
reliever, antihistamine, etc.

I give the adult leaders permission to seek medical attention for my child even if they can not reach me or the
emergency contact. This may include treatment, administration of medicine, clinical procedures or surgery. I
understand that any fees would be the responsibility of me or my insurance company.

I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold
HFHSCA, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred
through participation in the HFHSCA programs.

______________________________________________________ __________________
Signature of Parent/Guardian Date

Please return by

Friday, April 25! Shanty Town 2014: Medical/Permission Form

Participant Name ____________________________________________________________
Address ___________________________________________________________________
Home Phone ________________Email Address ___________________________________

Team Leader: ________________________________________________
The purpose of this form is to ensure consent from parents for participation in the Habitat for Humanity of
Sauk-Columbia Area (HFHSCA) Shantytown activities on May 17-18, 2014. It is also a form granting
permission for the treatment of minors who become ill or injured when the parents or guardians cannot be
reached to give consent for treatment. Every reasonable attempt will be made to contact the parent(s)/guardian
listed below.

Emergency Information: (Person to contact in case of emergency)

Name____________________________________________ Relation to Participant __________________
Phone Day___________________ Phone Eve______________________ Phone Other __________________
Address___________________________________________________________________________________
_________________________________________________________________________________________

Family Dr. Name ________________________________ Family Dr. Phone _______________________

Insurance Information: (please provide copy of insurance card)
Participant is covered by a medical insurance policy: Yes No
Insurance Company Name ________________________________________________________

Name of Policy Holder ___________________________________________________________

Group Policy Number ____________________________________________________________

Authorization Phone Number ______________________________________________________

Health History:
Allergies/special health concerns/needs: __________________________________________________
___________________________________________________________________________________
Medication(s) they can NOT take: _______________________________________________________
Medication(s) being taken: ____________________________________________________________
Special dietary needs: _________________________________________________________________
Any medical history that needs to be noted: ________________________________________________

Permission /Release/Authorization (for participants under 18)
I, the undersigned parent or guardian, do hereby grant permission for my child, _________________________,
to attend and participate in Habitat for Humanity Shanty Town 2014. I give the adult leaders permission to
provide basic aid to my child including the availability of basic over the counter medication including pain
reliever, antihistamine, etc.

I give the adult leaders permission to seek medical attention for my child even if they can not reach me or the
emergency contact. This may include treatment, administration of medicine, clinical procedures or surgery. I
understand that any fees would be the responsibility of me or my insurance company.

I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold
HFHSCA, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred
through participation in the HFHSCA programs.

______________________________________________________ __________________
Signature of Parent/Guardian Date

Please return by

Friday, April 25! Shanty Town 2014: Medical/Permission Form

Participant Name ____________________________________________________________
Address ___________________________________________________________________
Home Phone ________________Email Address ___________________________________

Team Leader: ________________________________________________
The purpose of this form is to ensure consent from parents for participation in the Habitat for Humanity of
Sauk-Columbia Area (HFHSCA) Shantytown activities on May 17-18, 2014. It is also a form granting
permission for the treatment of minors who become ill or injured when the parents or guardians cannot be
reached to give consent for treatment. Every reasonable attempt will be made to contact the parent(s)/guardian
listed below.

Emergency Information: (Person to contact in case of emergency)

Name____________________________________________ Relation to Participant __________________
Phone Day___________________ Phone Eve______________________ Phone Other __________________
Address___________________________________________________________________________________
_________________________________________________________________________________________

Family Dr. Name ________________________________ Family Dr. Phone _______________________

Insurance Information: (please provide copy of insurance card)
Participant is covered by a medical insurance policy: Yes No
Insurance Company Name ________________________________________________________

Name of Policy Holder ___________________________________________________________

Group Policy Number ____________________________________________________________

Authorization Phone Number ______________________________________________________

Health History:
Allergies/special health concerns/needs: __________________________________________________
___________________________________________________________________________________
Medication(s) they can NOT take: _______________________________________________________
Medication(s) being taken: ____________________________________________________________
Special dietary needs: _________________________________________________________________
Any medical history that needs to be noted: ________________________________________________

Permission /Release/Authorization (for participants under 18)
I, the undersigned parent or guardian, do hereby grant permission for my child, _________________________,
to attend and participate in Habitat for Humanity Shanty Town 2014. I give the adult leaders permission to
provide basic aid to my child including the availability of basic over the counter medication including pain
reliever, antihistamine, etc.

I give the adult leaders permission to seek medical attention for my child even if they can not reach me or the
emergency contact. This may include treatment, administration of medicine, clinical procedures or surgery. I
understand that any fees would be the responsibility of me or my insurance company.

I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold
HFHSCA, its leaders, employees and volunteer staff liable for damages, losses, diseases, or injuries incurred
through participation in the HFHSCA programs.

______________________________________________________ __________________
Signature of Parent/Guardian Date

Shanty Town – 2014
Pledge Form

1211 8th Street • P.O. Box 38 • Baraboo, WI 53913 • Phone: (608) 448-2888 • Website: www.hfhsca.org

Name: __________________________________________

Team Name: _____________________________________

Team Captain: ____________________________________

Habitat for Humanity of the Sauk-Columbia Area is a locally-controlled non-profit agency
dedicated to building a community where every man, woman, and child has a decent, affordable

place to live, a home that gives the family pride and security. Please bring form and any
donations collected with you to Shanty Town 2014!

Name Address City & Zip Phone $ Amount

Total Amount Collected

Make checks payable to Habitat for Humanity of Sauk-Columbia Area.

Questions? Call the HFHSCA office at: 608-448-2888 or e-mail: [email protected]

Shanty Town – 2014
Pledge Form

1211 8th Street • P.O. Box 38 • Baraboo, WI 53913 • Phone: (608) 448-2888 • Website: www.hfhsca.org

Name: __________________________________________

Team Name: _____________________________________

Team Captain: ____________________________________

Habitat for Humanity of the Sauk-Columbia Area is a locally-controlled non-profit agency
dedicated to building a community where every man, woman, and child has a decent, affordable

place to live, a home that gives the family pride and security. Please bring form and any
donations collected with you to Shanty Town 2014!

Name Address City & Zip Phone $ Amount

Total Amount Collected

Make checks payable to Habitat for Humanity of Sauk-Columbia Area.

Questions? Call the HFHSCA office at: 608-448-2888 or e-mail: [email protected]

Shanty Town – 2014
Pledge Form

1211 8th Street • P.O. Box 38 • Baraboo, WI 53913 • Phone: (608) 448-2888 • Website: www.hfhsca.org

Name: __________________________________________

Team Name: _____________________________________

Team Captain: ____________________________________

Habitat for Humanity of the Sauk-Columbia Area is a locally-controlled non-profit agency
dedicated to building a community where every man, woman, and child has a decent, affordable

place to live, a home that gives the family pride and security. Please bring form and any
donations collected with you to Shanty Town 2014!

Name Address City & Zip Phone $ Amount

Total Amount Collected

Make checks payable to Habitat for Humanity of Sauk-Columbia Area.

Questions? Call the HFHSCA office at: 608-448-2888 or e-mail: [email protected]

Shanty Town – 2014
Pledge Form

1211 8th Street • P.O. Box 38 • Baraboo, WI 53913 • Phone: (608) 448-2888 • Website: www.hfhsca.org

Name: __________________________________________

Team Name: _____________________________________

Team Captain: ____________________________________

Habitat for Humanity of the Sauk-Columbia Area is a locally-controlled non-profit agency
dedicated to building a community where every man, woman, and child has a decent, affordable

place to live, a home that gives the family pride and security. Please bring form and any
donations collected with you to Shanty Town 2014!

Name Address City & Zip Phone $ Amount

Total Amount Collected

Make checks payable to Habitat for Humanity of Sauk-Columbia Area.

Questions? Call the HFHSCA office at: 608-448-2888 or e-mail: [email protected]