Camp Kindle Day Camp Pre-Registration Form

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Dear Parents, Guardians and Organizations:

We hope this finds you well. This summer, Project Kindle, a locally run non-profit organization, will be offering a unique day camp program for children with special needs, chronic illnesses, and other life challenges- Camp Kindle Day Camp. This camp will offer a medically and emotionally supportive environment for each of its participants. Each participant will be paired with a counselor that they will work with in a one-on-one capacity throughout the week of camp. This program will help each child find positive meaning in their life by making friends, having fun, and sharing hopes with others confronting similar circumstances. Additionally, this camp will help primary caregivers by providing respite and necessary time for themselves. This summer day camp experience will emphasize teaching children life skills through math, science, music, and art. We believe that every camper will learn and grow through this program. Eva Payne established Project Kindle in 1998, and the organization has been running various summer camp programs for 22 years. For questions, please contact Minnow at glorimar@projectkindle.org.

Eligibility Criteria:
1. All youth must be between the ages of 5 and 12 on the first day of camp.
2. All youth must have a special need, disability, chronic illness, or other life threatening disease, and be medically cleared to participate in day camp activities.
3. Campers should reside in the Santa Clarita Valley, or within driving distance with a mode of transportation to and from the day camp location.
4. Campers must not have an aggressive background towards themselves or others. If camper poses a physical danger to himself or herself, other campers, of staff members at Camp Kindle Day Camp, he or she may be excused from the camping program at the discretion of the Camp Kindle Administration.

Forms and Registration:
Pre-Registration forms will continue to be accepted through June 1st. All applicants will remain confidential. We will be accepting up to 40 youth this summer. Once the Pre-Registration Form is sent in, reviewed and accepted, a confirmation packet will be sent out with additional release and medical forms.

If you have any questions about our program or would like more information, please contact us. Feel free to share the link to this form with any family/youth who would benefit from this program.

Thank You,

Camp Kindle Leadership Team

Email *

Camper Application Info

Please complete one form per applicant.

Pre-registration is open until session fills.

June 15-19 (Mon-Fri) - Camp Kindle Day Camp

First name *

Last Name *

Name child goes by

Date of Birth (MM/DD/YYYY) *

Current Grade In School *

Gender *

Male

Female

Please describe applicant's special needs.

This includes any and all medical and/or psychological diagnosis.

Any Allergies? *

Yes

If yes, please explain

Any Dietary Restrictions? *

Yes

If yes, please explain

Any Activity Restrictions? *

Yes

If yes, please explain

Approximate Weight *

If unknown, please estimate in pounds.

T-Shirt Size *

Child Small (6-8)

Child Medium (10-12)

Child Large (14-16)

Adult Small

Adult Medium

Adult Large

Adult XL

Adult XXL

Is applicant applying to any other summer camps this year? *

Yes

If yes, what camp(s)?

Please describe any medical needs, physical or mental challenges of the youth. *

Does your child have an Individualized Education Plan (IEP)? *

Yes

If yes, what is your child's educational disability? *

Parent or Guardian Contact Information

First and Last Name *

Relationship to Applicant *

Street Address *

Street Address

City *

State *

Zip *

Phone Number *

Alternate Phone Number *

Email Address *

How did you hear about Camp Kindle Day Camp?

If someone other than the child’s parent/guardian has completed this form, please complete this section:

First and Last Name

Relationship to Applicant

Street Address

City

State

Zip

Phone Number

Alternate Phone Number

Email Address

Does this child live with you?

Yes

Clear selection

If no, who does the child live with?

If the camper application is accepted a detailed medical profile and physical will be required to assist our staff in meeting the needs of each camper.

NOTE: All Information provided will be kept confidential in accordance with 381(e)(5) of the Public Health Service Act. 42 U.S.C. 247 c(e)(5). Project Kindle is a 501 c 3 organization and is independently operated

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