Camper Application
Camper Name *
Your answer
Birth Date *
Your answer
Age *
Your answer
School / Year in School *
Your answer
Parent Name *
(First, Last)
Your answer
Parent Email *
Your answer
Home Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Cell Phone *
Your answer
Home Phone
Your answer
Name of Partner Camp Location: *
Required
Camp Program/Camp Hours: *
Specify hours of operation for the Camp(s) chosen
Your answer
Below, please submit the starting dates of the weeks that you would like your child to attend camp, in order of preference.
Sessions begin June 19 through the week of July 24th.
For example, if you want your child in camp the week beginning June 19, but you are also available the week of July 10 and 17th, write 06/19 under 1st week, 07/10 under 2nd week, and 07/17 under 3rd week.
First Choice *
Your answer
Second Choice *
Your answer
Third Choice *
Your answer
For how many weeks of camp would you like a SummerAde Teen Mentor? *
Required
Do you prefer to have a male or female Teen Mentor (TM) for you child? We will make every attempt to match girl campers with female mentors and boy campers with male mentors.
Your answer
References
Please list 2 references (e.g., teachers or therapists) who know your child well. Please let your references know that we may contact them regarding your child.
Reference #1 *
Please include reference's first and last name, their email address and their relationship to camper
Your answer
Reference #2 *
Please include reference's first and last name, their phone number, email address and their relationship to camper
Your answer
Special needs
Please tell us about your child and their special needs. What in particular will a teen mentor need to know about your child? *
Your answer
Is your child receiving any special education services? If so, please describe. *
Your answer
Does your child have behavioral problems? If so, please describe. *
Include any instances of aggression.
Your answer
Goals for your child during their SummerAde experience
Please check 2 areas on which you would like us to focus *
Required
How did you hear about SummerAde? *
Your answer
PARENT WAIVER FORM & PHOTO CONSENT: Please read and check the boxes below. *
As parent and/or legal guardian and representative of my camper, I agree to abide by the rules of the camp for the health, safety and welfare of all campers. I authorize my camper to participate in all camp activities with the assistance of the Teen Mentor. I acknowledge that certain activities have an inherent risk of injury, and agree to assume the risk of injury associated with my camper’s participation in such activities. I release, indemnify and hold harmless, the SummerAde program, the Teen Mentor, associated representatives and sponsors from and against any injury, claims, damages, liabilities, costs and expenses, including attorney fees, allegedly sustained or incurred by, or asserted on behalf of, either (i) my camper or (ii) any other registered camper, that are attributable to, or a result of, my camper’s participation or conduct in activities while attending camp. SummerAde reserves the right to terminate the assistance provided by Teen Mentor and attendance at camp, if your camper’s behavior or conduct, in the sole and best judgment and discretion of SummerAde and/or the Teen Mentor, is unsatisfactory or otherwise determined to be detrimental, inappropriate or a distraction to the camp and/or other campers. I acknowledge that I have consulted with my attorney or other advisors to the extent I deem appropriate to evaluate this release and indemnity, and that I have not relied upon SummerAde for such advice.
Required
SummerAde relies on your donations.
Please visit the Donate page on our website so that we may continue to offer this program free of charge.
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