Section 1 of 1
Keep Connected Winter 2020 Registration
Keep Connected is a researched- based program from Search Institute that gives parents and youth an opportunity to learn about keys to positive family relationships during the transition to adolescence.
This program is a six week program for Middle School Youth and Parents/Guardians to reconnect, led by nationally trained facilitators.
Please fill the proceeding information out fully to ensure we have proper information for all family members.
This program is a six week program for Middle School Youth and Parents/Guardians to reconnect, led by nationally trained facilitators.
Please fill the proceeding information out fully to ensure we have proper information for all family members.
Parent/Guardian 1 Name ( First & Last):
Parent/Guardian 1 Name ( First & Last):
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Parent/Guardian 1 Email
Parent/Guardian 1 Email
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Parent/Guardian 1 Date of Birth
Parent/Guardian 1 Date of Birth
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Street Address
Street Address
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City
City
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State
State
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Ohio
other
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Zip code
Zip code
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Parent 1 Ethnicity
Parent 1 Ethnicity
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Caucasian
American Indian
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Parent/Guardian 2 Name ( First & Last):
Parent/Guardian 2 Name ( First & Last):
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Parent/Guardian 2 Email
Parent/Guardian 2 Email
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Parent/Guardian 2 Date of Birth
Parent/Guardian 2 Date of Birth
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Parent/Guardian 2 Street Address (if different from Parent 1)
Parent/Guardian 2 Street Address (if different from Parent 1)
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Parent/Guardian 2 City (if different from Parent 1)
Parent/Guardian 2 City (if different from Parent 1)
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Parent/Guardian 2 State (if different from Parent 1)
Parent/Guardian 2 State (if different from Parent 1)
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Parent/Guardian 2 Zip Code (if different from Parent 1)
Parent/Guardian 2 Zip Code (if different from Parent 1)
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Parent 2 Ethnicity
Parent 2 Ethnicity
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Caucasian
American Indian
Multi-racial
African American
Asian
Hispanic/Latino
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Youth participant 1 Full Name ( First & Last):
Youth participant 1 Full Name ( First & Last):
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Youth Participant 1 Date of Birth:
Youth Participant 1 Date of Birth:
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List any known allergies for Youth Participant 1:
List any known allergies for Youth Participant 1:
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List any medical concerns for Youth Participant 1:
List any medical concerns for Youth Participant 1:
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Youth 1 Ethnicity
Youth 1 Ethnicity
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Caucasian
American Indian
Multi-racial
African American
Asian
Hispanic/Latino
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Youth participant 2 Full Name ( First & Last):
Youth participant 2 Full Name ( First & Last):
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Youth Participant 2 Date of Birth:
Youth Participant 2 Date of Birth:
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Youth 2 Ethnicity
Youth 2 Ethnicity
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Caucasian
American Indian
Multi-racial
African American
Asian
Hispanic/Latino
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add "Other"
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List any known allergies for Youth Participant 2:
List any known allergies for Youth Participant 2:
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List any medical concerns for Youth Participant 2:
List any medical concerns for Youth Participant 2:
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Youth participant 3 Full Name ( First & Last):
Youth participant 3 Full Name ( First & Last):
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Youth Participant 3 Date of Birth:
Youth Participant 3 Date of Birth:
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List any known allergies for Youth Participant 3:
List any known allergies for Youth Participant 3:
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List any medical concerns for Youth Participant 3:
List any medical concerns for Youth Participant 3:
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List any medical concerns for Youth Participant 3:
List any medical concerns for Youth Participant 3:
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Status Of Head of Household
Status Of Head of Household
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Married ( 2 parent)
Single Parent
Partnership
Guardianship
Foster Parent
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Annual Household income:
Annual Household income:
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$0-$25,000
$26,000-$50,000
$51,000-$75,000
$76,000-$100,000
greater than $100,000
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I have an additional youth and will fill out additional paperwork when I get to the first Keep Connected program day:
I have an additional youth and will fill out additional paperwork when I get to the first Keep Connected program day:
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yes-1 more
yes-2 more
yes- more than 2 more
No
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This is a 6 week program to be held every Tuesday evening from 5:30-7:00. The cost of the program is $25. Families who attend all six sessions will be compensated by receiving a $20 gift card at the last session October 22, 2019. The $25 is required to be paid on the day of /prior to the first session. Families who join the program late or who leave the program early will still be required to pay the $25 fee, but no compensation will be provided. A refund less $10 may be provided to families who leave the program due to medical reasons, with valid medical documentation. Camp Fire reserves the right to cancel any program with as much notice as possible. You will receive a full refund. $40.00 will be charged for check or charges not honored by your bank. Camp Fire cannot be financially responsible for lost or stolen items. Label all of your child’s belongings carefully. Do not send valuables to camp (no large sums of money, electronics, keepsakes, etc.)
This is a 6 week program to be held every Tuesday evening from 5:30-7:00. The cost of the program is $25. Families who attend all six sessions will be compensated by receiving a $20 gift card at the last session October 22, 2019. The $25 is required to be paid on the day of /prior to the first session. Families who join the program late or who leave the program early will still be required to pay the $25 fee, but no compensation will be provided. A refund less $10 may be provided to families who leave the program due to medical reasons, with valid medical documentation. Camp Fire reserves the right to cancel any program with as much notice as possible. You will receive a full refund. $40.00 will be charged for check or charges not honored by your bank. Camp Fire cannot be financially responsible for lost or stolen items. Label all of your child’s belongings carefully. Do not send valuables to camp (no large sums of money, electronics, keepsakes, etc.)
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I agree to the financial policies
I do not agree to the financial policies and will address my concerns with the office
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My child (or ward) has permission to participate in the camp activities during the session(s) and program(s) for which he/she is enrolled. I understand that camp activities have inherent risks, and that reasonable measures will be taken to safeguard the health and safety of all participants. I will assure that my child is properly prepared for all activities including having proper clothing and equipment,being in good health, willing and able to participate in camp activities, and willing and able to abide by camp policies and follow directions of camp personnel. I understand and agree to cooperate with all regulations and procedures, and I waive any claims against Camp Fire National/Sandusky County, except for claims arising from gross negligence or willful acts of the organization or its agents that may arise from participation in the activities of the organization. I understand the duties that my child will be asked to perform and I am aware of the responsibility that goes with those duties. My child has my permission to carry out such and I will not hold Camp Fire Sandusky County, or its agents, responsible for accident of injury to my child while she/he is a volunteer at day camp. I understand that the use of cell phones or electronic devices will not be allowed during camp sessions. I understand that I will be notified as soon as possible in case of any emergency, unusual illness or injury affecting my child. In the event I cannot be reached, I hereby authorize the alternate contact people to act on my behalf, and authorize the camp to contact a physician to provide whatever medical or surgical treatment is necessary. I accept responsibility for the cost of such medical treatments. I have provided a complete picture of my child’s physical, emotional and mental health, including all medications, on this registration form, and will provide (on the first day of camp) updated health information on the form provided by Camp Fire Sandusky County. I will assure that my child will not bring valuables, money, electronic items, weapons, alcohol or illegal drugs to camp. I will monitor my child’s use and distribution of any photos taken at camp to assure that they are not used inappropriately nor posted on the Internet. In the event that my child (or ward) is photographed, filmed or recorded while participating in Camp Fire activities, Camp Fire Sandusky County or other partnering organization approved by Camp Fire may use the photo, film or recording for publicity, promotional or instructional purposes. I waive any rights for royalties or for compensation arising from the use of the photographs. Camp Fire will not disclose the names of campers or youth in any of their promotional materials including on the website.
My child (or ward) has permission to participate in the camp activities during the session(s) and program(s) for which he/she is enrolled. I understand that camp activities have inherent risks, and that reasonable measures will be taken to safeguard the health and safety of all participants. I will assure that my child is properly prepared for all activities including having proper clothing and equipment,being in good health, willing and able to participate in camp activities, and willing and able to abide by camp policies and follow directions of camp personnel. I understand and agree to cooperate with all regulations and procedures, and I waive any claims against Camp Fire National/Sandusky County, except for claims arising from gross negligence or willful acts of the organization or its agents that may arise from participation in the activities of the organization. I understand the duties that my child will be asked to perform and I am aware of the responsibility that goes with those duties. My child has my permission to carry out such and I will not hold Camp Fire Sandusky County, or its agents, responsible for accident of injury to my child while she/he is a volunteer at day camp. I understand that the use of cell phones or electronic devices will not be allowed during camp sessions. I understand that I will be notified as soon as possible in case of any emergency, unusual illness or injury affecting my child. In the event I cannot be reached, I hereby authorize the alternate contact people to act on my behalf, and authorize the camp to contact a physician to provide whatever medical or surgical treatment is necessary. I accept responsibility for the cost of such medical treatments. I have provided a complete picture of my child’s physical, emotional and mental health, including all medications, on this registration form, and will provide (on the first day of camp) updated health information on the form provided by Camp Fire Sandusky County. I will assure that my child will not bring valuables, money, electronic items, weapons, alcohol or illegal drugs to camp. I will monitor my child’s use and distribution of any photos taken at camp to assure that they are not used inappropriately nor posted on the Internet. In the event that my child (or ward) is photographed, filmed or recorded while participating in Camp Fire activities, Camp Fire Sandusky County or other partnering organization approved by Camp Fire may use the photo, film or recording for publicity, promotional or instructional purposes. I waive any rights for royalties or for compensation arising from the use of the photographs. Camp Fire will not disclose the names of campers or youth in any of their promotional materials including on the website.
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Diners will be potluck style weekly and families are encouraged to bring a dish to share and eat together.
Diners will be potluck style weekly and families are encouraged to bring a dish to share and eat together.
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I understand Diner is potluck style and will plan to bring a dish to share weekly
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List any dietary restrictions your family has to ensure we inform everyone in the group ( we cannot guarantee families will not bring items in your restricted needs, but this will be encouraged) put NA if none:
List any dietary restrictions your family has to ensure we inform everyone in the group ( we cannot guarantee families will not bring items in your restricted needs, but this will be encouraged) put NA if none:
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I have read, understand and accept all of the terms and conditions set forth in this application. I agree to sign this form electronically by typing my full legal name on the below line, which will act in the same regard as a formal signature on a written paper. Please type Parent/Guardians Full Name below:
I have read, understand and accept all of the terms and conditions set forth in this application. I agree to sign this form electronically by typing my full legal name on the below line, which will act in the same regard as a formal signature on a written paper. Please type Parent/Guardians Full Name below:
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