Camp Better Together Registration
Please complete all required fields to successfully register your child for Camp Better Together. This camp is for students entering grades 5-8. There are limited spots available so please don't delay in registering. This camp will be a fun and engaging way for youth to make new friends, strengthen leadership skills, build a positive mindset, receive education regarding drug and alcohol prevention, and dream about their career path. Campers will receive breakfast, lunch, and a snack every day, as well as a t-shirt and other fun goodies.

This camp is led by staff and volunteers from the Springfield Promise Neighborhood, Project Woman, and Clark County Partners in Prevention. All efforts will be made to keep your child safe and well cared for. Please fill out this registration form fully and include current contact information.

This camp will be held:
Dates: June 10-14
Time: 9am-4pm
Location: Lincoln Elementary

If you have any questions, please contact us at: 937-505-0330
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Email *
Camper's Name *
Camper's Gender *
Camper's Ethnicity *
Camper's Race *
Camper's Age *
Camper's Incoming Grade (This camp is only for incoming 5th-8th graders) *
Camper's T-shirt size *
Camper’s Home Address *
Camper's Zip Code *
Does your camper have any dietary restrictions? Please Explain: *
Does your camper have any health/medical conditions we need to be aware of? Please explain: *
Parent/Guardian's Name *
Parent/Guardian's Phone Number *
Alternate Emergency Contact Name *
Alternate Emergency Contact Number *
Please list the names of all people permitted to pick up your camper: *
Is your camper allowed to walk home from camp? *
Does your camper have other dismissal arrangements?
I give my permission for my child to be in photographs and/or video. *
By typing my full name, I give Springfield Promise Neighborhood, Clark County Partners in Prevention, and Project Woman permission to care for my child, make appropriate choices to keep them safe. I understand that in the event medical intervention is needed, every attempt will be made to contact the persons listed on this form.  In the event I cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the activity leader to secure medical treatment or hospitalization for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed.  Coverage by Springfield Promise Neighborhood through its accident policy will be used as a backup for what my family's insurance does not cover. I understand all reasonable safety precautions will be taken at all times by Springfield Promise Neighborhood, Clark County Partners in Prevention, Project Woman and their agents.  I understand the possibility of unforeseen hazards and the inherent possibility of risk.  

I, the undersigned and parent/legal guardian of the student identified on this registration form, hereby assume all risks and hazards incidental to the conduct of activities and transportation to and from camp wile participating in this program. I do hereby absolve, indemnify, and hold harmless Springfield Promise Neighborhood, Clark County Partners in Prevention, Project Woman, their leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the student named on this form.
A copy of your responses will be emailed to the address you provided.
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