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Camp Catalyst Registration Form
Camp Catalyst 2023 Registration Form
"
*
" indicates required fields
Step
1
of
10
10%
Camper Information
Name
*
First
Last
Birthday
*
MM slash DD slash YYYY
Age (as of 6/19/2023)
*
Shirt Size
*
Youth S
Youth M
Youth L
XS
S
M
L
XL
2XL
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
School Attending in Fall 2023
Grade Attending in Fall 2023
Parent/Guardian Information
Name
*
First
Last
Relationship to Camper
*
Parent
Legal Guardian
Other
If other, please explain.
Address (if different from Camper's)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Primary Phone
*
Secondary Phone
Email
*
Emergency Contacts
Emergency Contact #1 Name
*
First
Last
Relationship to Camper
*
Primary Phone
*
Secondary Phone
Email
Emergency Contact #2
*
First
Last
Relationship to Camper
*
Primary Phone
*
Secondary Phone
Email
Authorization for Pick-Up
Please list additional adults, if any, other than the parent/guardian who are authorized by the camper's parent/guardian to pick up the camper.
Authorized Adult #1
First
Last
Primary Phone
Secondary Phone
Authorized Adult #2
First
Last
Primary Phone
Secondary Phone
Authorized Adult #3
First
Last
Primary Phone
Secondary Phone
Unauthorized for Pick-Up
Please list any adults who may NOT pick up the camper. This includes adults who may not have contact with the camper according to a custody agreement or court order.
Unauthorized Pick-Up #1
First
Last
Unauthorized Pick-Up #2
First
Last
Unauthorized Pick-Up #3
First
Last
Medical Information
Please provide any necessary medical information.
In the past year, has the camper required any counseling or hospitalization?
*
Yes
No
If yes, please explain.
In the past year, has the camper had any operations or serious injuries?
*
Yes
No
If yes, please explain.
Does the camper have an emotional, intellectual and/or physical disability?
*
Yes
No
If yes, please explain.
Does the camper have activity encouraged or limited by a physician?
*
Yes
No
If yes, please explain.
Does the camper have dietary modifications due to medical or religious guidelines?
*
Yes
No
If yes, please explain.
Does the camper use assistive devices including but not limited to glasses, hearing aids, leg braces, etc.?
*
Yes
No
If yes, please explain.
Does the camper have any allergies?
*
Yes
No
If yes, please explain.
Does the camper use an Epi-Pen?
*
Yes
No
If yes, will you be sending an Epi-Pen with your camper?
Yes
No
Additional Medical Information
Camper's Physician or Primary Care Provider
*
First
Last
Physician's Phone
*
Physician's Office Name
Physician's Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Immunizations
Please provide information regarding the camper's immunization record.
Are the camper's immunizations are up to date as required by Indiana Public Schools?
*
Yes
No
If the camper's immunizations are NOT up to date as required by Indiana Public Schools, please list the dates below OR attach a copy of the camper's immunization record below.
DTP, Polio, Varicella (chicken pox), Influenza B, Hepatitis B, MMR or Measles or Mumps or Rubella.
Date of most recent Tetanus Shot
*
MM slash DD slash YYYY
Date of most recent COVID-19 Vaccine
*
MM slash DD slash YYYY
Copy of Camper's Immunization Record
Please upload a copy of the camper's immunization record.
Max. file size: 256 MB.
Treatment Authorization
Treatment Authorization
*
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. I hereby give permission to the medical personnel selected by New Hope of Indiana to order X-rays, routine tests, treatment, and necessary transportation for the person herein described. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by New Hope of Indiana to secure and administer treatment, including hospitalization, for the person named above. The complete forms may be photocopied for trips off site.
I agree to the treatment authorization as described below.
Medication Administration
Please list any medication, both prescription and over-the-counter, that your camper will need during camp hours. Include the medication name, dose, specific days that the camper will need it, and any other pertinent information.
Medication #1
List the medication name and dose.
Medication #1 Administration
Select which days Medication #1 should be administered by Camp staff.
Monday
Tuesday
Wednesday
Thursday
Friday
As needed.
Medication #1 Additional Notes or Instructions
Medication #2
List the medication name and dose.
Medication #2 Administration
Select which days Medication #2 should be administered by Camp staff.
Monday
Tuesday
Wednesday
Thursday
Friday
As Needed
Medication #2 Additional Notes or Instructions
Medication #3
List the medication name and dose.
Medication #3 Administration
Select which days Medication #3 should be administered by Camp staff.
Monday
Tuesday
Wednesday
Thursday
Friday
As Needed
Medication #3 Additional Notes or Instructions
Medication #4
List the medication name and dose.
Medication #4 Administration
Select which days Medication #4 should be administered by Camp staff.
Monday
Tuesday
Wednesday
Thursday
Friday
As Needed
Medication #4 Additional Notes or Instructions
Additional Medication Information
Medication Administration Authorization
*
Although we encourage medication to be given to your child before or after camp, we understand there might be a need for your child to receive medication during camp hours. A procedure has been established for medications to be administered by trained camp staff. Medications must be brought to camp in the original containers with clearly written directions for usage.
I hereby give my consent for the staff to administer medication(s) to the Camper as described in this section.
I agree to the medication administration authorization as described above.
Camper Health and Therapeutic Assessment
Camper's Gender
*
Female
Male
Nonbinary
Camper's Weight
*
# pounds
Camper's Height
*
#feet #inches
Camper's Diagnosis (if applicable)
Does the camper have an Individualized Education Plan (IEP) that you'd be willing to share?
Yes
No
Motor Needs
Uses wheelchair, adaptive equipment, etc.
Recreational Needs
Requires physical assistance, verbal queuing, etc.
Visual Needs
Uses glasses, blindness, etc.
Seizures
Describe frequency, treatment, type, etc.
Hearing Needs
Uses hearing aids, assistive technology, etc.
Verbal or Nonverbal
Describe language skills or communication needs.
Allergies
Please include all allergies such as bees, food, medication, etc.
Behavioral and Sensory Needs
Successful calming techniques, triggering events, etc.
Feeding Needs
Can feed self; requires some assistance with getting lunch opened and ready to eat; feeding tube; pureed diet; chopped diet; etc.
Does the camper have any of the following illnesses or symptoms?
Please check all that apply and explain in the following section.
Heart Disease
Diabetes
Asthma
Cancer
Seizure
Does the camper have any other medical, emotional or behavioral needs? Do you have any other relevant concerns? Please explain.
Please include any information regarding transfers, asthma, diabetes, shunts, adaptive equipment, etc.
Interests and Goals
Please let us know a little more about the camper.
Please describe the camper's interests and hobbies.
*
Please describe the camper's previous camp experiences.
*
Please describe the camper's hopes for this camp experience or goals that they want to work on during camp.
*
Consent and Liability Agreements
Please read and consent to the following statements.
Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19
*
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
New Hope of Indiana has put in place preventative measures to reduce the spread of COVID-19; however, the organization cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending summer camp with the New Hope of Indiana could increase your risk and your child(ren)'s risk of contracting COVID-19.
By consenting to this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending summer camp with New Hope of Indiana and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID-19 at summer camp with New Hope of Indiana may result from the actions, omissions, or negligence of myself and others, including, but not limited to, New Hope of Indiana employees, volunteers, and program participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself including, but not limited to, personal injury, disability, death, illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)'s attendance at summer camp with New Hope of Indiana or participation in New Hope of Indiana programming ("Claims"). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless New Hope of Indiana, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of New Hope of Indiana, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in New Hope of Indiana program.
I agree to the risk and waiver of liability described here.
Media Release
*
This media release hereby releases the use of the camper's photograph, audio, video, article, artwork or other representation of the camper in/on New Hope of Indiana's website, social media, newsletter and/or other publications for the promotion of New Hope of Indiana and/or its programs. This includes but is not limited to the publication of the camper's photo on Facebook, Instagram, LinkedIn, Twitter and any other social media platform as chosen by New Hope of Indiana. This also includes but is not limited to the use of a camper's photograph in email marketing, print marketing or web marketing as chosen by New Hope of Indiana.
This release will expire one year from the date of consent.
I agree to the media release as described here.
Camper Drop Off/Pick Up Agreement
*
I agree to drop off my child or arrange for their drop off in the designated drop off time period and pick them up or arrange for their pick up within the designated pick up time period. I agree to pick them up or make arrangements to pick them up as quickly as possible if camp staff notifies me that they become ill during camp hours.
I agree to sign the camper sign-in/sign-out sheet at each drop off and pick up each day the camper attends camp.
I agree to pay an additional $5 fee for every 15 minutes that a camper remains after the designated pick up time period ends.
I agree to the drop off/pickup agreement as described here.
Camper Demographics
New Hope of Indiana receives funding from different city, state, federal and private agencies that require us to report demographic information on the users of our programs and services. Please complete the following information for this purpose. This information is kept confidential.
Camper's Racial Background
American Indiana
Asian
Black/African American
White/Caucasian
Multiracial
Other
Prefer not to say
Camper's Ethnicity
Hispanic/Latinx
Not Hispanic/Latinx
Prefer not to say
Camper's Gender
Male
Female
Prefer to self Describe
Prefer not to say
Camper's Disabilities
Physical
Intellectual
Emotional
Combination
Prefer not to say
Parent/Guardian Marital Status
Married
Single
Divorced
Prefer not to say
Parent/Guardian Employment Status
Employed for Wages
Unemployed
Student
Stay at Home Parent
Other
Prefer not to say
Parent/Guardian Education
Student
High School Graduate
Technical School Graduate
College Graduate
Other
Prefer not to say
Parent/Guardian Household IncomeLevel
Below $9,999
$10,000-$14,999
$15,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
Over $60,000
Prefer not to say
Consent and Registration
Consent
*
To the best of my knowledge, all the information contained in this registration form is accurate and up to date.
I agree.
Comments
This field is for validation purposes and should be left unchanged.
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