Hope's Haven Camp

General Information

Camper Name(Required)

First Middle Last

Preferred Name/Nickname(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Gender(Required)

Male

Female

Birth Date(Required)

Age(Required)

Will your child be attending camp with a sibling (biological, foster, or adoptive)?(Required)

Yes

Sibling's Name(Required)

Do you recommend them being in the same group for activities?(Required)

Yes

Explanation:(Required)

Parent / Guardian Information

Foster Care Status(Required)

Please Check One: (Required)

Child is currently in foster care

Child was at some point in foster care

Child is residing with(Required)

Foster Family

Adoptive Family

Biological Family

Kinship

Group Home

Parent / Guardian Name(Required)

First Last

Parent / Guardian Relationship(Required)

Parent / Guardian Phone(Required)

Parent / Guardian Alternate Phone

Parent / Guardian Email(Required)

Alternate Emergency Contact

Emergency Contact Name(Required)

First Last

Emergency Contact Relationship(Required)

Emergency Contact Phone(Required)

Emergency Contact Alternate Phone

Emergency Contact Email(Required)

Caseworker Information

Caseworker Name

First Last

Caseworker Phone

Caseworker Email

Caseworker Originating County

Agency / Group Home Name

Camp Information

Please select the corresponding camp to which your child will be attending using the grade indicated(Required)

August 5-8 (Summit Grove / Grades 5-8)

Returning Camper(Required)

Yes

T-Shirt Size(Required)

T-Shirt Size Type(Required)

Adult

Youth

Transportation(Required)

Parent / Guardian

Agency

Hope’s Haven

I understand that my child is required to sleep in the cabin of their biological gender/sex.(Required)

Yes

Medications

Does your child take medications?(Required)

Yes

Medications(Required)

Medication Name

Dosage

Time(s)

Medical Provider

Medical Provider Name(Required)

Medical Provider Phone(Required)

Policy Number(Required)

ID Number(Required)

Health / Behavior History

Health / Behavior History (Check all that are applicable)

Please explain checked answers in the space below, noting the number of the question(s).(Required)

Please list any modifications that work well for your child.(Required)

Please list any restricted activities.(Required)

Please use the space below to provide any additional information about the campers physical, emotional, and mental health or behavior about which the camp should be aware. If nothing is applicable, please write N/A.(Required)

Immunization History

Please, fill in the date(s) of each immunization.

Diphtheria, tetanus, pertussis (DTaP) or (TdaP)

Tetanus booster (dT) or (TdaP)

Mumps, measles, rubella (MMR)

Polio (IPV)

Haemophilus influenzae type B (HIB)

Pneumococcal (PCV)

Hepatitis A

Hepatitis B

Varicella (chicken pox)

Meningococcal meningitis (MCV4)

Tuberculosis (TB) test

Parent / Guardian Authorization

Medical Release: I certify that all of the information above is true and complete to the best of my knowledge. I agree to notify Hope’s Haven if any change occurs in medical condition before arriving at camp. The person named above has permission to engage in all activities except as noted above. I hereby give permission to Hope’s Haven to provide routine health care, administer prescribed medications, and seek emergency medical treatment. I give permission to Hope’s Haven to arrange necessary related transportation for the person named above. I agree to the release of any records necessary for insurance purposes. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Hope’s Haven to secure and administer treatment, including hospitalization for the person named above. I hereby waive and release Hope’s Haven and its volunteers/staff from any and all liability for any injury or illness incurred at camp.

Confidentiality Statement: All information regarding the person named above will be held confidential within pertinent volunteers/staff on a need-to-know basis for the purposes of determining admission and providing the best experience possible to the person named above and others in attendance. However, confidentiality may be breached in the event of an emergency or if a safety concern arises that requires attention. Hope’s Haven requires all volunteers/staff to report any concerns of child abuse according to Pennsylvania law.

Signature(Required)