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MAKING CONNECTIONS, CHANGING LIVES.

Camper Application

Step 1 of 2

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Camper's Information
Child's Name*
First Last
Child's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender*
- Male
- Female
Birthdate*
MM slash DD slash YYYY
Age (as of August 2023)*
Please enter a number from 7 to 12.
Emotional Age*
School Grade in Fall 2023*
Reading Level*
What date does your child start the 2023-2024 school year?*
MM slash DD slash YYYY
Learning Disabilities*
- Yes
- No
Please elaborate*
The child is living with:*
- Foster Parent(s)
- Group Home
- Relative(s)
- Adoptive Parent(s)
- Birth Parent(s)
Name of people living in the household with the camper (including siblings)*
Name Relation to camper
What is the primary language spoken at home?*
Has this child attended Signs Of Hope Camp in the past?*
- Yes
- No
When was the most recent year they attended?*
Please explain any unusual family circumstances that make camp especially important for the child.*
for example, a recent crisis, being moved in foster placement, etc.
Primary Caregiver's Information
Primary Caregiver's Name*
First Last
Caregiver's relationship to child:*
Caregiver's Primary Phone Number*
Caregiver's Secondary Phone Number
Caregiver's Work Phone Number
Caregiver's Email
Emergency Contact Information
Name*
First Last
Emergency Contact's Relationship to Child:*
Emergency Contact's Phone Number*
Does your child have a social worker?*
- Yes
- No
Social Worker's Information
County*
- Santa Clara County
- San Mateo County
Social Worker's Name*
First Last
Social Worker's Email*
Camper Details
What is the child's swimming ability*
- Good
- Moderate
- Poor
- Unknown
Emotional/Behavioral History
- Select All
- Agressiveness
- Bedwetting
- Biting
- Eating Disorders
- Hyperactive
- Learning Disabilities
- Lying
- Has Recently Moved in Foster Placement
- Night Terrors
- Nightmares
- Runs Away
- Sexually Acting Out
- Steals
- Tantrums
- Withdrawn
Please check all that apply
Please elaborate if you can*
Does your child require one-on-one supervision?*
- Yes
- No
Please explain including typical disciplinary measures if applicable:*
Any specific activities to be encouraged?*
Any specific activities to be restricted?*
Camper Welcome Bag
Upon arrival, each camper receives a drawstring backpack filled with camp essentials donated by partnering churches. This donation drive serves to provide awareness and a service opportunity to partnering churches as well as bless your child with some new camp necessities. Your child will receive: a sweatshirt, warm PJ's, swimsuit and a towel
T-shirt/Sweatshirt Size*
- Child Small
- Child Medium
- Child Large
- Adult Small
- Adult Medium
- Adult Large
Swimsuit Size*
- Child Small
- Child Medium
- Child Large
- Adult Small
- Adult Medium
- Adult Large
Please provide a brief description of your child's clothing preferences:*
The more descriptive you are with their preferences, the better we can find items they will love. (favorite colors, sports teams, tv show characters, "dresses tomboy")
Camper's Health History
Doctor's Name*
First Last
Doctor's Phone Number*
Please check all that have ever applied:
- Balance Problems
- Respiratory Problems
- Heart or Circulation Problems
- Hypoglycemia
- Hay Fever
- Insect Bites
- Pulmonary Edema
- Dizzy Spells
- Back Problems
- Anaphylactic Shock
- Diabetes
- Drug Allergy
- Musculoskeletal Allergies
- Foot Problems
- Seizure Disorders
- Poison Oak
- Fainting
- Other
Please provide details regarding above selected:*
Indicate date of illness, severity, complications, and any residual impairments.
Indicate any known allergies*
Indicate any known illnesses*
Indicate any known special needs/limitations*
DTP Series Booster*
MM slash DD slash YYYY

Please fill in dates of basic immunization or most recent booster
Polio OPV (Sabin)*
MM slash DD slash YYYY

Please fill in dates of basic immunization or most recent booster
Measles Vaccine (live)*
MM slash DD slash YYYY

Please fill in dates of basic immunization or most recent booster
German Measles (Rubella)*
MM slash DD slash YYYY

Please fill in dates of basic immunization or most recent booster
Tetanus Booster*
MM slash DD slash YYYY

Please fill in dates of basic immunization or most recent booster
Tuberculin (TB) Test*
MM slash DD slash YYYY

Please fill in dates of basic immunization or most recent booster
Mumps Vaccine (live)*
MM slash DD slash YYYY

Please fill in dates of basic immunization or most recent booster
Please add any additional comments related to HEALTH and MEDICATION below:*
Medication
**All medication sent to the camp must be in original container with the pharmacy label on it and will be held and administered by the nurse.
Is your child taking any medication?*
- Yes
- No
What medication is your child taking?*
Medication: Dosage: Times administered: Purpose:

Waiver and Release: Permission Form for Minors*
I agree to the privacy policy.
I, the undersigned parent, legal guardian, or foster parent of the above-named Minor(s), hereby give my permission for my child(ren)’s participation in Help One Child’s “Signs of Hope Camp” held at Mission Springs Frontier Ranch from August 6-10, 2023 (the “Event”). I have directed my child(ren) to cooperate and conform to directions and instructions of persons responsible for the Event and/or their volunteers.

In signing this form, I warrant and represent that I am the parent, legal guardian, or foster parent of my child(ren), that I am 18 years of age or older; and I indemnify and hold harmless, release and discharge Help One Child and Mission Springs Association, Inc. and their constituent organizations, officers, agents, employees, and volunteers from any and all claims for personal injuries, property damage or wrongful death that my child(ren) may suffer as a result of participating in the Event, whether or not such injuries or damages are caused by the negligence (active or passive) of any of the entities or individuals named or described above.

I agree that in the event of an injury as a result of my child(ren)’s participation in the Event, including transportation to and from the Event, recourse for the payment of any hospital, medical, dental, or related costs and expenses will be paid either by me or my spouse, accident, hospital or medical insurance, or any available benefit plan of mine or my spouse.

I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician, surgeon, or dentist licensed under the Medical Practice Act and Dental Practice Act. As a parent, legal guardian, or foster parent, I am responsible for the health care decisions of my child(ren) and am authorized to consent to services to be rendered, and the law requires no other consent.

I hereby give permission to the physician selected by the Event supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician or dentist.

I hereby authorize the making of photographs, motion pictures, videotapes, recordings, or other memorializing of said event and my child(ren)’s participation therein.
Consent
The information contained herein is correct so far as I know, and the above-named minor has permission to engage in all prescribed program activities, except as noted. The undersigned does hereby authorize the directors of Help One Child’s Signs of Hope Camp or such substitute as they may designate as agent for the undersigned to consent to an X-Ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the provision of the Medicine Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp or elsewhere. This authorization will remain effective while the above minor is en route to and from or involved or participating in any camp program unless revoked in writing by the undersigned and delivered to Help One Child.
Signature*
Your Name*
First Last
Relationship to child:*
Todays Date*
MM slash DD slash YYYY

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