Camp Oak Hallows Application Form

Part  1

How to fill out this form

Digitally: Use a PDF editor such as DocHub with Smart-Aligned Text and Stamps

Print: Use black or blue ink and scan back to digital when complete

Basic Camper Information

Full Name: __________________________________________________________________

Gender, Sex, Sexuality: _______________________________________________________

Age: Elementary(6-11y)◯  Junior High(11-14y)◯  High School(14-18y)◯   _______________

Race: Wh◯  Bl◯  Ltnx◯  Asn◯  Indgs◯  Mixed◯  Other◯ :_________________________

School Enrollment: Public Private◯ Homeschool◯  Charter/Magnet◯  None/Other◯

City, County, or District: _______________________________________________________

How you discovered Camp Oak Hallows: Web search◯  Social Media◯  Word of Mouth◯

Explain why you are interested in Camp Oak Hallows: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Home Life

Residence:         With parents◯  With one parent/split parents◯  With a family guardian◯

With Unrelated Guardian◯ Foster◯  Group Home◯  Shelter◯

Homeless◯  Other◯: ______________________________________________

How long has the child lived in the residence? ____________________________________

This is a:        Permanent Residence◯  Temporary Residence◯

Transition Residence◯  Long-Term Residence◯  

Enrollment Facilitator(s)

Parent◯  Related Guardian◯  Unrelated Guardian◯  Foster Representative◯

Home Authority◯  Youth Homelessness Prevention Authority◯  School Representative◯

Other◯ :____________________________________________________________________

Financial Status

Will NOT need financial aid

◯ MAY need financial aid

◯ Will need financial aid

◯ Scholarship/Grant:___________________________________________________________

◯ Work-Study (Fill out Work-Study Application in Part 2)


About Your Camper (Be as complete and honest as possible)

◯ Camper is independent self-managing (Over 13)

◯ Camper needs basic assistance with: Hygiene  Time Management  Mobility  Problem Solving

Other areas of assistance: _______________________________________________________

◯ Camper is neurotypical and has no mental illness

◯ Camper has shown signs of or has been diagnosed with: _Anxiety  _Depression  _Mania  _OCD  _Post-Traumatic Stress  _General Stress   _ADD  _ADHD  _Anger/Outbursts

Other/notes:__________________________________________________________________

________________________________________________________________________________________________________________________________________________________

◯ Camper is abled and has no disabilities

◯ Camper is/has: _HOH/Deaf  _VI/Blind  _Autism  _In a wheelchair  _Prosthetic limbs

◯ Camper has a disability (describe):______________________________________________ ________________________________________________________________________________________________________________________________________________________

◯ Languages: _English  _Spanish  _Vietnamese  _German  _Other:_____________________

◯ Food Allergies:                        ◯ Med Allergies                ◯ Permission to Administer

_____________________                _____________________        _Insulin

_____________________                _____________________        _Epi-Pen

_____________________                _____________________        _Benedryl/Antihistamine

_____________________                _____________________        _Advil/NSAID

_____________________                _____________________        _Orajel, Aloe gel, Neosporin

◯ Regularly scheduled medications        Name                         Dose

M  Br  LM  Lu  MA  Di  N _________________________        _____________________________

M  Br  LM  Lu  MA  Di  N _________________________        _____________________________

M  Br  LM  Lu  MA  Di  N _________________________        _____________________________

M  Br  LM  Lu  MA  Di  N _________________________        _____________________________

M  Br  LM  Lu  MA  Di  N _________________________        _____________________________

◯ As-Needed medications Name                Dose

 _________________________        _____________________________

 _________________________        _____________________________

 _________________________        _____________________________

 _________________________        _____________________________

 _________________________        _____________________________

◯ Allergic to latex        ◯ Allergic to adhesive        ◯ Allergic to fragrance

◯ Other allergy: ______________________________________________

◯ Dietary restrictions: _GF  _DF  _Vegetarian  _Vegan  _Pescetarian  _Kosher  _Halal

Other/Notes:__________________________________________________________________

Does not like/will not eat: ________________________________________________________

Favorite Color: ________________________ Favorite Food: _________________________

Favorite Book(s):  ____________________________________________________________

Favorite Movie(s): ____________________________________________________________

Favorite Music:  ______________________________________________________________

Likes: ________________________       Dislikes: ________________________

________________________                ________________________

________________________                ________________________

________________________                ________________________

________________________                ________________________

________________________                ________________________

Sleep Cycle: ◯Morning person  ◯Night Owl  ◯It’s a surprise every day, honestly

Breakfast energy drink: ◯Coffee  ◯Tea  ◯Powerade  ◯Fruit Juice  ◯Protein drink

Studying: ◯Independent study  ◯Group study  ◯Scheduled “class” study

Evaluations: ◯Write an essay  ◯Give a presentation  ◯Take a test  ◯Have an oral exam

Projects: ◯Work alone  ◯Work with a partner  ◯Work in a group

Exercise: ◯Swim/water aerobics  ◯Walk/run  ◯Yoga/stretches/cardio  ◯Team sport  ◯Gym/weights ◯Bike  ◯Acro/tumbling  ◯Dance  ◯Kayak/rowing  ◯Solo sport

◯ Member of an organization:  _Girl Scouts  _Boy Scouts  _Other:_____________________

◯ Member of a faith: _________________________________________________________

◯ Athlete/competitor in:  ______________________________________________________

Course and Credit History (NON-STUDENTS SKIP)

Underlined courses are required for Foundation Program graduation.

English 1  ◯English 2  ◯Language & Composition  ◯Literature & Composition

◯Biology  ◯Chemistry  ◯Physics

◯World Geography  ◯World History  ◯US History  ◯Government  ◯Economics

◯Pre-Algebra  ◯Algebra 1  ◯Algebra 2  ◯Geometry  ◯Pre-Calculus  ◯Calculus

Language Other Than English 1  ◯LOTE 2  ◯Two (2) Arts  ◯One (1) P.E./Athletics

AP Test scores:

Course                                Year         Score                Course                                Year        Score

___________________________________                ___________________________________

___________________________________                ___________________________________

___________________________________                ___________________________________

SAT:  ______________________________                ACT:  ______________________________

Other courses passed: _________________________________________________________

________________________________________________________________________________________________________________________________________________________

In the past, this student has had success in ◯ AP  ◯ IB  ◯ GT  ◯ IS  ◯ Accelerated/Honors

Endorsement Plan: Y / N ________________________________________________________


Living at Camp

When filling out this section, consider your mobility and the needs of your disabled or more-needing peers.

What are your NEEDS, and what are your WANTS? Just because you don’t NEED something doesn’t mean you won’t get it.

Needs                                                Wants/Okay with

◯Bottom bunk or lower bed                        ◯Top bunk or elevated bed

◯Immediate bathroom                        ◯Bottom bunk or lower bed

◯Immediate electrical outlet                        ◯Desk space

◯Wheelchair accessible sink,                ◯Hanging closet with low shelves

shower with bench seat, handrails                ◯Drawers/dresser

◯Yard/outdoor access for SA/ESA                ◯Porch/deck access

◯HELP Call button                                ◯1-2 roommates

◯Low-height storage         (2’-4’)                        ◯3-4 roommates

◯Elevated storage (4’-5’)                        ◯Up to 5 roommates

◯Other needs: ________________                ◯Rooming with someone with an animal

_____________________________                ◯Limited electrical outlets

_____________________________                ◯Loft cottage cabins (NOT WCA, no temp control)

_____________________________                ◯“Hobbit” cabins (NOT WCA, no temp control)

Campers may bring personal electronics and/or small appliances such as a mini-fridge, personal microwave, box or tower fan, coffee pot, radio/stereo, computers and tablets, cell phones, et cetera with the understanding that Camp Staff is not responsible for these items should they be damaged. Missing and stolen items should be reported immediately. Unreported items are not the responsibility of Staff. Campers should be mature enough to manage their own possessions while at Camp. Don’t send your camper with items they are not prepared to maintain, use, or keep track of. Restricted and monitored WiFi is available to Campers.

Are you coming to Camp with a friend, sibling, or group? Y / N

If yes, list who is coming with you and whether you want to be housed together:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you bringing a Service Animal, Emotional Support Animal, or a caged, indoor pet? Y / N

◯Dog well-trained for Service tasks                ◯Dog or cat well-trained for ESA

◯Hamster, gerbil, rat, etc        ◯Bird                ◯Snake        ◯Other: __________

Name, Age, Breed:_____________________________________________________________

I understand that the caring and keeping of my SA, ESA, or Pet is not the responsibility of Camp Staff or other campers, I will provide food for my animal, and maintain a clean living space. I will pick up after my animal, and only allow my animal outdoors on-leash or in a fenced yard. My dog/cat is friendly to other animals with whom it may share limited yard time.

I understand that at any time, if my non-service animal has becomes disruptive, I may be asked to return my non-service animal to my off-camp home.

I understand that if I am unable to properly care for my animal, I will be asked to leave my animal in the better care of my off-camp home or another determined arrangement.


Support Team Members

A camper’s Support Team consists of trusted adults that work together to keep the camper safe, healthy, and happy during their time at Camp. Everyone’s Support Team is a little different, as they serve different needs. Those familiar with Section 504 may recognize this as the group of administrators and educators who meet to discuss and assess student needs and status.

“Home” refers to off-camp family, guardians, or authorities

Care Companion: An adult from “home” in the Camper’s life who will stay on-camp and with their camper at all times to attend to needs such as mobility, behavior management, or learning

(Fill out Care Companion form)

Knowledgeable Companion: A sibling, relative, or close friend from “home” who is equipped for tasks such as answering questions or alerting for help in emergencies.

This person will spend the majority of their time with or near their Camper. Must be 13+ y/o

Name, age: _________________________________________________________________

Med Tech: A qualified medical staff member who will be familiarized with medication and aid needs for day-to-day health upkeep. This person is the Point of Contact for “home” ICE.

Assigned staffer:______________________________________________________________

Lab Supervisor: A staff member who monitors and manages Lab space such as computers and technology or chemistry. STEM-interested students should have this team member.

Assigned staffer:______________________________________________________________

Librarian: A staff member who works in the Library space or research lab.

Independent Study students/Companion tutored should have this team member.

Assigned staffer:______________________________________________________________

House Captain:_____________________________________________________________

Rec Supervisor: A staff member who works in Rec and Athletics. Campers who hope to spend a lot of time using equipment, including waterfronts, should have this team member.

Assigned staffer:______________________________________________________________

Prefects:                                        Admins and other staff:

________________________________        ________________________________

________________________________        ________________________________

________________________________        ________________________________

Home Contacts:

________________________________        ________________________________

________________________________        ________________________________

________________________________        ________________________________

________________________________        ________________________________

________________________________        ________________________________

Alert Home about Contact:                        Block/Prevent Contact:

________________________________        ________________________________

________________________________        ________________________________

________________________________        ________________________________


Activities and Interests

Mark any and all that your Camper may want to check out during their session

◯Computer and Electronics Lab        ◯Research Lab                ◯Journalism/Photo Lab

◯Chemistry Lab                        ◯Music Lab                        ◯Art/Digital Art Lab

◯Pool, waterfront                        ◯Kayaks, Canoes                ◯Snorkels

◯Exploring trails                        ◯Fresh Garden                ◯Barn/Pastures

◯Indoor gym, weights, machines        ◯Outdoor gym, track                ◯Sensory/OT gym

◯Theater, acting club                        ◯Choir, vocal club                ◯Band, music club

◯All-Camp movie night                ◯All-Camp outdoor games        ◯All-Camp bonfire

What things not on this list are you interested in?

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Tuition

Tuition payments are accepted in cash, via PayPal, and checks with DL# and Phone #.

Camper tuition can be supplemented by paid tasks and donated items. Views our blog “Camp Cash.”

◯Cash         ◯PayPal.me/CampOakHallows                ◯Check:_____________________

                                Check-in date:                        Check-out date:

◯Short stay                        ____________________        ____________________

◯One week (Sun-Fri)                ____________________        ____________________

◯Two weeks (Sun-Sun-Fri)        ____________________        ____________________

◯Long stay                        ____________________        ____________________

NON-STUDENT CAMPERS: (STUDENTS ON NEXT PAGE)

Youth Camper (5-12)                        Junior Camper (12-14)                Senior Camper (14-17)

$150/week                                $200/week                                        $250/week

◯+$20 Barn Program                        ◯+$20 Barn Program                ◯+$30 Barn Access/Program

◯+$20 Waterfront Program                ◯+$20 Waterfront Program        ◯+$25 Waterfront Program

◯+$10 Athletics Program                ◯+$10 Athletics Program        ◯+$15 Rec/Athletics Program

◯+$10 Non-Service Animal                ◯+$10 Non-Service Animal        ◯+$10 Non-Service Animal

◯+$5 Robotics Program                ◯+$5 Robotics Program        ◯+$5 Technology Program

◯-$25 Group of 4+                        ◯-$30 Group of 4+                ◯-$40 Group of 4+

SUB SUM:

__________________________        _________________________        _________________________

__________________________        _________________________        _________________________

Campers not in specialized programs will still have some access to specialized areas and do not need to pay the additional tuition.

Specialized programs are facilitated during certain advertised times. Visit our website for more information.


STUDENT CAMPERS: (NON-STUDENTS ON PREVIOUS PAGE)

Primary Schoolers Grades 1-3/Age 6-9                Elementary Schoolers Grades 4-5/Age 9-11

        ◯$50/week                                        ◯$75/week

Grades 6-8/Age 11-14                Grades 9-10/Age 14-16                        Grades 11-12/Age 16-18

◯$100/week                        ◯$125/week                                ◯$150/week

Prep and Study Courses (does not include exam vendor costs, one-time fee)

◯UTHS 150-day Online Course ($100)                ◯UTHS Credit-by-Exam ($50)

Course:_________________________                Exam:_________________________

 _______________________________                 ______________________________

◯STAAR Reading/Math 3-5 Gr ($50)        ◯STAAR Writing 4 Gr ($60)        ◯STAAR Science 5 Gr ($75)

◯STAAR Writing 7 Gr ($100)        ◯STAAR Science 8 Gr ($150)        ◯STAAR Social Studies 8 Gr ($100)

◯STAAR Reading 6-8 Gr ($75)        ◯STAAR Math 6-8 Gr ($125)        ◯EOC English I ($100)

◯EOC English II ($100)        ◯EOC Algebra I ($150)                ◯EOC Biology ($125)

◯EOC US History ($125)        ◯EOC English III ($75)                ◯EOC Algebra II ($175)

◯TASC Texas ($50)                ◯HiSET Texas ($50)                ◯GED Texas ($100)

Weekly resource costs: Only select labs you will need tutoring in. These students have priority access.

Students who don’t need tutoring will still have access to labs when not filled by tutored students.

◯Technology Lab ($40)                ◯Chemistry Lab ($40)                ◯Research Lab ($30)

◯Art/Digital Art Lab ($20)        ◯Music Lab ($15)                ◯Rec House ($15)

◯Primary Learning Lab ($20)        ◯Elem. Learning Lab ($30)        ◯Writing Lab ($25)

◯Lower Science Lab ($30)        ◯Physical Fitness Coach ($40)        ◯Barn/Waterfront Access ($30)

ALL CAMPERS:

◯Private Housing (Support companion/no roommates, bathroom shared) $100/week

◯Dorm Housing (1-2 roommates, shared bathroom) $80/week

◯Small Unit Housing (2-4 roommates, private unit bathroom) $60/week

◯Group Housing (3-5 roommates, private group bathroom) $50/week

◯Low-Tech Housing (1-3 roommates, no climate control, shared bathhouse) $40/week

◯Bunk Housing (6-9 roommates, bunk bathroom) $30/week

◯BYOH (RV, Tiny House, Camper) $25/week for power/water

Meal Plan: weekly cost

◯3 Meals/day $125        ◯5 Small meals/day $100        ◯BYOM $30 for kitchen use/storage

Laundry

◯$10/week with our soap        ◯$5/week BYOS

◯-$10 Little Sibling        ◯-$10 Knowledgeable Companion        ◯-$25 Staff family & friends discount

◯-$25 Prefects                ◯-$20 Certified Lifeguard 16+                ◯-$20 Licensed Food Handler

◯-$______ Supply Donation value discount

◯+$______ Give the gift of camp and donate to cover tuition scholarships and grants for others

TOTAL SUM:

__________________________

__________________________


Session Goals

What does this Camper hope to achieve during their stay?

Academic Goals:                                        Personal Goals:

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◯Start a test/exam prep course                                ◯Learn a new skill:______________________

◯Continue a test/exam prep course                        ◯Meet a fitness goal: ____________________

◯Complete a test/exam prep course                        ◯Complete a project: ____________________


Camp Oak Hallows Application Form

Part 2

Camper Adult Support Companion

Insert Photo of Adult Companion

Full Name: ______________________________________

DOB: _____________  Relation: _____________________

Certifications, if any: ◯CPR/AED  ◯Lifeguard  ◯Food Handler ◯Child Care  ◯Teaching  ◯Degree:______________________

Cell Phone:  _____ - _______ Email: ______________________

ICE Contact:

Name:___________________ Relation: ____________________

Phone #:_________________

Name:___________________ Relation: ____________________

Phone # _________________

Mark all that are true

◯Providing own learning materials/curriculum                ◯Using COH materials/curriculum

◯Administering/facilitating learning and activities        ◯Helping COH facilitate learning and activities

◯Responsible for camper’s medications                ◯Releasing medications to COH staff

◯Responsible for own/camper’s meals                        ◯Purchasing a meal plan

◯Housing with specific camper:___________________        ◯Housing separately/with other adults

◯BYOH (RV, Tiny House, Camper)                        Housing/cost: ___________________________

◯Responsible for multiple campers: ______________________________________________________

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View camper housing information to fill in your housing cost line.

Mark materials you/your camper(s) will need provided/access to:

◯Computer, Tablet        ◯Textbooks, Study Guides        ◯Other print resources/books

◯Chemistry Lab        ◯Music Lab        ◯Lower Science Lab        ◯Computers and Technology Lab

◯Electronic media (movies, music)        ◯Athletic equipment        ◯Kitchen, food storage

◯Laundry, soap        ◯The Sharing Closet        ◯Hygiene Products        ◯Refrigerated Med storage

◯Photography Lab         ◯Pool, waterfront        ◯Kayaks, canoes        ◯Barn/Pastures

Meal Plan: weekly cost

◯3 Meals/day $135        ◯5 Small meals/day $110        ◯BYOM $30 for kitchen use/storage

Laundry: weekly cost

◯$10/week with our soap        ◯$5/week BYOS

TOTAL: ____________________

◯Cash         ◯PayPal.me/CampOakHallows                ◯Check:_____________________


Work-Study Application

◯Cover entire tuition cost         ◯Supplement tuition cost                        ◯Earn Camp Cash

Cost: ________________        Amount:______________                                ◯Field trips

                                        Hour                                                ◯Exam fee

Item                                Value        commitment:                                        ◯Laundry

Sweeping/Dusting                $2/hr        _____                                                ◯Housing

Vacuuming                        $2/hr        _____                                                ◯Camp Store

Shelving books                $2/hr        _____                                                ◯Lab cost

Cleaning glass                $2/hr        _____                                                ◯Meal Plan

Basic maintenance tasks        $2/hr        _____                                                ◯Program cost

Weed whacking                $5/hr        _____                Total hours: ______

Gardening                        $5/hr        _____                Est. total amount: ______

Mopping                        $5/hr        _____                *must have required valid certification,

Clean toilets                        $5/hr        _____                and over 16 y.o.

Clean kitchen                $5/hr        _____                **must provide proof of ability to produce

Laundry                        $5/hr        _____                quality materials, approved by staff

Write study guides**        $5/hr        _____                and guardians

Record audio books        $5/hr        _____                Basic Maintenance: Change light bulbs,

Tutor                        $8/hr        _____                unclog drains, repair stuck/squeaking doors

Lifeguard/Waterfront*        $8/hr        _____                Higher Maintenance: Fix technology issues,

Cook/serve*                        $8/hr        _____                pest control, pool care

Mowing                        $8/hr        _____                Advanced Maintenance: Painting buildings,

Barn cleaning                $8/hr        _____                tree trimming, construction, off-site errands

Higher maintenance task        $8/hr        _____

Advanced maintenance**        $10/hr        _____

TASK                        TIME IN                TIME OUT                STAFF SIGN


Personal Belongings

Campers are welcome and encouraged to bring items from home, but things can be broken or lost.

List your valuable belongings, their model info and/or serial numbers, and any identifiers.

On “normal looking” items, it’s a good idea to use a permanent marker to write your name, or a symbol that can be used to recognize your item, like an X on the page that’s your birthdate (118: November 8.)

Example:         Space Gray iPhone 6S with damage to upper right corner, FFMTNH94GRYG

                Leatherbound “Chronicles of Narnia” with piece of tape on inside front cover

                Size 9 red Converse low tops with white, frayed laces and scuffs on toes

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The Sharing Closet

Camp Oak Hallows knows that sometimes, money is tight, and Campers may not have everything they need for their stay. If you need extra items (clothes, shampoo, toothpaste, et cetera,) please let us know. Write it here, or talk to us during Check In. Toiletry items are free, clothes can be borrowed.

If you would like to donate to the Sharing Closet, please contact us and bring your items on the day of Check-in so their value may be estimated and your tuition may be discounted.

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Camp Store

Campers can use their Camp Cash to purchase items from the Camp Store during their session, or guardians may buy items for their camper during Check In or Check Out. For safety reasons, we do not allow Campers to have cash, cards, checks, or other form of money with them at Camp.

Guardians can control what their Campers are allowed to purchase.

◯Caffeinated/carbonated beverages        ◯Candy and “junk” snacks        ◯Sports drinks (Powerade)

◯Gum                ◯Mints                ◯Tea bags        ◯Coffee grounds        ◯Order delivery from off-camp

◯Disposable Cameras                        ◯Postage/Stationery                ◯Lotion, chapstick, nail polish

◯Camp clothing        ◯Camp gear (backpack, sunglasses)                ◯Toiletries/Laundry supplies