Camp Create! 2024 Student Admissions Application

This form is to be completed by the parent or legal guardian of the student seeking admission to the camp. General Communications regarding the camp program will be made to parents, through email. In addition to this application, several consent and confirmation signatures will be required of the student's legal guardian on the first day of the program.

*Please note that camp instructors are credentialed artists and educators, but do not have specialized training to deal with unique medical or behavioral circumstances.

Information about the program is available on the Pro-Art website.

Student Information

First Name (student) *

Last Name (student) *

Date of Birth *

Home Address (physical- Not P.O. Box) *

Please include the full street address with street number, street name, city, state, and zip-code.

School student attends *

Grade (Rising) *

Health Insurer (H.I.) *

Please indicate the health insurer that the student applicant is covered by. If none, please write "none" in the field below.

H.I. Policy # *

Please provide the health insurer's policy number that the student applicant is covered by. If the child is not currently covered by health insurance, please write "N.A."

Medications *

Please list any medications that the student applicant uses, which would influence their participation in our program or which you believe that the program staff should be aware of and/or assist with. Please specifically note if your child carries and uses an Epi-Pen or an Inhaler. If the student applicant does not take any medications, please write "none" in the field below.

Allergies *

Please list all allergies that the student applicant is known to have, including food and medication. Please write "none" in the field below if none are known.

Disabilities *

Please list any disabilities that the student applicant has been identified as having that you believe would impact their participation in our program or that you would like our staff to know about. Please include physical, mental/emotional, social and learning disabilities. If none are known, please write "none" in the field below.

Medical conditions *

Please list any medical conditions that the student applicant has that you believe will impact their participation in our program or that a doctor should be aware of in an emergency situation requiring medical treatment. If none, please write "none" in the field below.

Dietary Restrictions *

Please any dietary restrictions that we should be aware of in working with the student applicant. We will do our best to accommodate eating restrictions while attempting to serve the interests of all program participants, as appropriate. Please note that food allergies should also be included in the Allergy field above. If the student applicant has no dietary restrictions, please write "none" in the field below.

Custodial Information- Parent/Legal Guardian

Name-Guardian *

Primary/Emergency Phone Number *

Email-Guardian *

Mailing Address- Guardian *

Secondary Phone Number

Contact Preference

Custodians *

Please list the first and last names of any and all individuals that you give permission to drop-off or pick-up the student applicant from the camp program over the duration of its operation. Please inform those individuals that they will have to physically sign the student applicant in or out of the program and that they will need to provide legal picture identification to assure their identity to camp staff. Please note, advanced notice must be made for any individual, that is not the legal guardian of a child, to be permitted to pick the child up from the program.

Custodial Restrictions *

Please list any individuals legally restricted from having contact with or being in the proximity of the student applicant. If the student applicant has no custodial restrictions, please write "none" in the field below.

Conflicts-Scheduling *

Please list any known scheduling conflicts for which the student applicant may need to be absent from the camp program. If the student applicant has no scheduling conflicts, please write "none" in the field below.

Notes

Please list any other information you think the camp staff should know to best serve the student applicant through this program.

Consent: There are several forms of consent required of the legal guardian of a participating student, to be obtained at the onset of the program. These include the consent to initiate emergency medical treatment and to allow designee/s of the camp program to take photos and/or video of your child (documentation required for grant reporting). In addition, the camp program will ask for your consent to abide by the camp program's policies, including restrictions on the possession and use of cell phones by students and program attendance expectations. Checking the box below indicates that you understand the student applicant's participation in the camp program may be conditioned on your consent, as their legal guardian, in these matters.

By checking this box, I affirm my understanding that my child's participation may be conditioned on my consent to the program's forthcoming policies and procedures. *

By checking this box, I affirm that I am the legal guardian of the student named in this application and that the information I have provided is accurate to the best of my knowlege. *

Camp Create! 2024 Student Admissions Application

Student Information

Custodial Information- Parent/﻿Legal Guardian

Custodial Information- Parent/Legal Guardian