Camp Hope Registration

Name *

First

Last

Gender *

Female
Male

Date of Birth *

Age *

Weight *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian's Name *

First

Last

Phone *

Alternate Phone *

Parent/Guardian's Email *

Please Select the weeks your camper would like to attend Ages 6-21 (6-12 for non-disabled): Tuition Rates: $350.00 per week or $700.00 per week for 1:1 staffing. *Note: We are closed on the July 4th *

Primary Emergency Contact *

First

Last

Phone *

Relationship to Camper *

Alternate Phone *

Secondary Contact (If primary is unavailable *

First

Last

Phone *

Relationship to Camper *

Alternate Phone *

People authorized to remove camper from camp or in emergency: Please include all who may provide transportation, including any friends, family or agencies. If an agency (such as a school) is providing transportation, you do not need to list driver names, just the agency who is authorized. Camp staff reserves the right to hold a camper on site if someone who is not on list attempts to pickup a camper. In a case where someone different is picking up, please call or send note in with camper.

Camp Hope Annual Programmatic Release Form

I hereby authorize, the camper registered in this form to: Participate in the Summer Camp Program conducted by the Center of Hope Foundation including (but not limited to) community access trips and recreational activities including swimming that may be conducted at places other than the camp site but approved by this program. Be transported to any of the above by staff or volunteers of the agency and hold the operator of any agency owned vehicle harmless. Be transported by means other than agency owned vehicles when necessary and approved by the Center of Hope Foundation and hold the operator of any such vehicle harmless. I will allow the Center of Hope Foundation staff to provide emergency first aide and if necessary, transport the individual to the emergency room, or contact an ambulance if needed. I understand that in the case of an emergency, all efforts will be made by the Center of Hope Foundation staff to contact the Parent/Guardian and the emergency contact person listed with the agency. I will hold the Center of Hope Foundation and the associated camp programs and facilities harmless in the event of injury.

Signature *

Clear Signature

Date *

Consent

I affirm that my consent was not obtained under coercion or undue influence, and that it may be withdrawn at any time without fear of consequence. This consent must be reauthorized annually. Consent may be withdrawn at any time by the parent/guardian by notifying the Center of Hope Foundation in writing. Person Securing Consent: Ryan Thompson, Assistant COO, Center of Hope Foundation, Inc.

Parent/Guardian's Name *

First

Last

Signature *

Clear Signature

Date *

I, grant permission to the Center of Hope Foundation to videorecording/photograph/use camper’s likeness or pictures in: Agency Brochures - To be used as a marketing tool for the Center of Hope/Camp Hope Program Social Story - To introduce families and individuals seeking information/admission to the Center of Hope Agency Marketing - For example: video, Facebook, YouTube, agency Website I understand staff will respect my privacy and not videotape/photograph when I ask them not to. I understand staff will respect my privacy and not videotape/photograph me in embarrassing situations. I affirm that my consent was not obtained under coercion or undue influence and that it may be withdrawn as specified without fear of consequence. *

Yes
No

This consent must be reauthorized annually. Consent may be withdrawn at any time by the camper/guardian by notifying the Center of Hope Foundation in writing or by calling Ryan Thompson, Assistant COO at 508-764-4085.

Signature *

Clear Signature

Date *

Camp Hope - Child Questionnaire

Camper's Name *

First

Last

Communication/Mobility/Communication Skills - check any that apply. *

Mobility Concerns - check any that apply.

Miscellaneous Information Behavioral Concerns - Please indicate any concerns that staff should be made aware of:

Does camper have any strong fears, such as animals, thunderstorms, height, water, etc. If “yes” please indicate fear and explain method for dealing with fears:

Does your child need assistance in the bathroom or other personal care? List area of need and level of care required: Independent, Verbal Prompting/Reminders, Physical Assistance:

Does your child require modified foods? Example: Food cut small, soft foods, g-tube feed, no food by mouth

Please list any other information you would feel helpful in providing the best camping experience:

Please Note: Staff will do everything in their power to address behavioral concerns, but due to the nature and environment of the camp, behaviors must be able to be managed by our trained staff. Behavior that is unmanageable will result in un-enrollment for the remainder of the camp season.

Camp Hope Medical Form

Camper's Name *

First

Last

Gender *

Female
Male

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physician's Name *

First

Last

Physician's Phone Number *

Medical Insurance Carrier *

Insurance Number *

File Upload

Click or drag a file to this area to upload.

Camp Hope Registration

Camp Hope Annual Programmatic Release Form

Consent

Camp Hope - Child Questionnaire

Camp Hope Medical Form

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