Camp Hope Registration Please enable JavaScript in your browser to complete this form.Name *FirstLastGender *FemaleMaleDate of Birth *Age *Weight *Parent/Guardian's Name *FirstLastParent/Guardian's Email *Please Select the weeks your camper would like to attend Ages 6-21 (6-12 for non-disabled): Tuition Rates: $400 per week or $775 per week. *Note: We are closed on the July 4th *Week 1: 6/29 – 7/3Week 2: 7/6 – 7/10Week 3: 7/13 – 7/17Week 4: 7/20 – 7/24Week 5: 7/27 – 7/31Week 6: 8/3 – 8/7Week 7: 8/10 – 8/14Week 8: 8/17 – 8/21Primary Emergency Contact *FirstLastSecondary Contact (If primary is unavailable *FirstLastPeople 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.Parent/Guardian's Name *FirstLastI, 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 I affirm that my consent was not obtained under coercion or undue influence and that it may be withdrawn as specified without fear of consequence. *YesNoThis 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 Consent may be withdrawn at any time by the camper/guardian by notifying the Center of Hope Foundation in writing or by calling Ryan Thompson, Assistant COO at 508-764-4085. Camper's Name *FirstLastCommunication/Mobility/Communication Skills - check any that apply. *VerbalNon-verbalLimited ability to communicateOne-to-two-word sentencesMultiple word sentencesGood receptive skillsSign languageMobility Concerns - check any that apply.Needs assistance to get into vehicleNeeds assistance on uneven groundNeeds assistance with stairsWheelchairWalkerMiscellaneous 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. Camper's Name *FirstLastGender *FemaleMalePhysician's Name *FirstLastPhysician's Phone Number *Medical Insurance Carrier *Insurance Number *Submit
