ENVISION LEAD GROW ENTREPRENEURSHIP SUMMER CAMP EXPERIENCE 2017
Envision Lead Grow is on a mission to increase the rate of entrepreneurship in girls. We are
committed to serving 1,000 middle school girls in 2017 and creating a community to support their
success.
Sounds like something you or a middle school girl you know would be interested in? Apply! We will
be in following cities the summer of 2017:
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Memphis, TN - University of Memphis (June 12-16)
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North Carolina Triad- University of North Carolina at Greensboro (June 19-23)
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Metro Atlanta (June 26-30)
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Baltimore, MD - Spark Baltimore (July 10-14)
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Philadelphia, PA (July 17-21)
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Richmond, VA - Virginia Commonwealth University (July 24-28)
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Norfolk, VA - Old Dominion University (July 31-August 4)
So what would you be getting if you were accepted into the program? ​An incredible-life changing
experience, which includes:
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A 1-week immersion entrepreneurship program (see dates above) for middle school girls, with the
opportunity to win a $500 award
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Ongoing weekly mentorship in peer groups
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Monthly support group webinar sessions
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The chance to participate in the Envision Lead Grow Fellows Program in 2018.
In order to qualify, you must be:
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A rising 5th grade-9th grade girl
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Able to attend all five days of camp
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Able to show a 2.5 grade point average
Registration Form
(Please complete one form per camper)
Participant's Name: _____________________________________________ DOB:________________
Age by 6/12/17: _______
Current Grade: _______________ School Participant Attends: ___________________________________________
Address: ___________________________________ City: _____________________ State: ___
Zip Code: _________
Adult T-Shirt Size (check one): ___S ___M ___L ___XL
Parent/Guardian Name: ____________________________________ Relationship: __________________________
Address: ___________________________________ City: ____________________ State: ___ Zip Code: ________
Daytime Phone: _________________________________ Cell Phone: ____________________________________
Email Address: ___________________________________
Alternate Contact Name: ____________________________________ Relationship: _________________________
Address: ___________________________________ City: ____________________ State: ___ Zip Code: ________
Daytime Phone: _________________________________ Cell Phone: ____________________________________
Email Address: ___________________________________
All other persons authorized to pick up your child from camp:
Contact Name: _________________________________________ Relationship: ___________________________
Contact Name: _________________________________________ Relationship: ___________________________
Contact Name: _________________________________________ Relationship: ___________________________
Camp Attending (check one):
___Memphis, TN (June 12-16)
___North Carolina Triad (June 19-23)
___Metro Atlanta (June 26-30)
___Baltimore, MD (July 10-14)
___Philadelphia, PA (July 17-21)
___Richmond, VA (July 24-28)
___Norfolk, VA (July 31-August 4)
Parent/ Guardian Signature: _____________________________________________ Date: ____________________
Doctor’s Name: _____________________________________ Phone Number: _____________________________
Insurance Company: ________________________________ Policy Number: ______________________________
Allergies/ Health Considerations:
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Please indicate if your child has special needs: ___YES ___NO If yes, please describe:
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Any medication we are permitted to administer to your child during camp: __________________________________
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I authorize my child to take or be administered the above medication and therefore waive my right to informed
consent of treatment in the event that neither parent/guardian can be reached in the case of an Emergency or any
other issues resulting from the administration of this medication.
Parent/ Guardian Signature: _____________________________________________ Date: ____________________
Lunch will be provided each day of camp. Students with special dietary needs will need to let us know, and
we will be in contact if we will not be able to accommodate. Dietary Requirements: _______________________
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CAMP PERMISSION SLIP
1. CAMP INVOLVEMENT. I wish to allow my child ___________________________ to participate
in the Entrepreneurship Summer Experience Camp (“Camp”) facilitated by EnvisionLeadGrow, Inc.,
(“ELG”) which involves entrepreneurship training, interactive workshops and other activities and
understand that such activities that may be hazardous or otherwise involve a risk of physical injury to
participants (the “Activities”).
2. LIABILITY WAIVER. I assume all risks of injury resulting from the Activities and release ELG, its
corporate affiliates, contractors, vendors, officer, agents, sponsors, volunteers or representatives of
any kind (collectively “Releases”) from any claims or suits resulting from my participation in Camp. I
also agree to indemnify Releases in the event of any loss, damage or claim arising from or relating in
any way to my participation in any of the Activities.
3. PHOTO RELEASE. I also give permission to ELG to use, reproduce, and/or distribute
photographs, films, video-tapes, and sound recordings of the participant for use in materials created
for purposes of promoting the activities of ELG. I also waive any right that I may have to inspect or
approve any finished products or the advertising copy or printed matter that may be used in
connection therewith or use to which it may be applied.
4. ELG LICENSE. I also give ELG the right to use, reproduce, and/or distribute in any original
format or as a duplicate ideas, concepts, processes, discoveries, developments, materials,
improvements, designs, artwork, content, or other works, created by me or others during the
duration of the Camp.
I am the parent or legal guardian of the child whose name and signature appear above. I have read
and understand this Waiver, Release and Indemnification Agreement, and consent on behalf of the
Participant to its terms.
Date: _________________
Signature:
Print Name:
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Teacher/ Counselor Recommender Name: _______________________________ Phone number: _____________
Email address: __________________________________ Relationship: ___________________________________
Below please write your comments concerning the student’s ability to participate in the Envision Lead Grow
Summer Experience. Please pay particular attention to the student’s potential to work hard during the week of
camp. Include any special qualities this student has that you believe distinguish her from her peers.
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On a scale of 1 to 5, how would you rank the student in these following categories? (1 being not applicable, 3 being
neither true nor false and 5 being extremely applicable)
Intellectual Curiosity: ___
Relative Maturity: ___
Confidence: ___
Self Control: ___
Leadership: ___
Motivation: ___
Intent to start a business: ___
Signature of Teacher/Counselor: _______________________________________ Date: ______________________
Campers: Please write a 1-2 paragraph short essay explaining why you would like to attend the Envision Lead
Grow Summer Experience.
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How did you find out about the Envision Lead Grow Summer Experience (check one):
___ Social Media
___ Email from Envision Lead Grow
___ Friends or teachers in your school
Other:___________________________________
Will you attend every day of camp from Monday through Friday (9 a.m. to 5 p.m.)? (check one) ___Yes
___No
If no, please explain:____________________________________________________________________________
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Mail or Email your application ​along with your most recent report card​ to:
Application Coordinator
Envision Lead Grow
1215 North Military Highway
Suite 730
Norfolk, VA 23502
Email: [email protected]
Phone: 757-529-0118
The registration for the Envision Lead Grow Summer Camps will close May 20, 2017.
Notifications of acceptance to the camps will be made no later than June 1, 2017.