CAMP APPLICATION
Application Fee: $50 | Camp ID#:_____________ | Date Paid:_____________
PARENT/GUARDIAN INFORMATION
Date: _________________________________________________________________________________________________
Parent(s)/Guardian(s) name(s): ___________________________________________________________________________
Address: ____________________________________________________ City: ___________________
Zip: ___________
Home Phone: ___________________________ Cell: _________________________ Work: _________________________
Email Address: _________________________________________________________________________________________
Marital Status: ¨Married
¨Single
¨Divorced
¨Separated
¨Widowed
Employer Name: _______________________________________________________________________________________
Information regarding income and ethnicity is for statistical purposes and is required for grants obtained to support the summer
day camp and make it as affordable as possible to all participants.
Household Income Range: ¨10K–15K
¨15K–20K
¨20K–30K
Select income source if less than 10K: ¨Unemployment
¨Disability
Ethnicity of Household (please list all): ¨Black/African American
¨Hispanic
¨30K–40K
¨Multiracial
¨40K–50K
¨Foster Care
¨Caucasian
¨50K+
¨Retirement income
¨Asian
¨Native American
TRANSPORTATION
Transportation available at an additional charge ($15/week per child) for those that need it.
Will you need transportation provided to get your child(ren) to and from camp? ¨Yes
If yes, please fill out transportation form.
¨No
FOR OFFICE USE ONLY
Registration Fee: ____________________________ Date Paid: ____________________________________________
Parent Name: _______________________________ Sibling Name: _________________________________________
Total camp fee due: __________________________ Balance Due: __________________________________________
Transportation: ¨Yes ¨No (both ways or one way? __________________________________________________ )
Cost for Transportation: ______________
Payment: ________________________
The EPICENTER at Edgewood | 1918 Pulaski Highway, Edgewood, MD 21040 | 443-981-3742
CAMP APPLICATION
CAMPER INFORMATION
(If not attending school, proof of age is required)
Full Name: ____________________________________________________________________________________________
Goes by: ______________________________________________________________________________________________
Date of Birth: ________________
Age: _______ Relation to you: ____________________
Gender: ¨Male
¨Female
Address (if different from above): ___________________________________________________________________________
City: ____________________________________________________________________
School Name: ______________________________________________
Zip: ________________________
Grade completed as of June this year: _________
Does your child have an IEP? ¨Yes ¨No
If yes, may we review a copy in order to better serve your child? ¨Yes ¨No
Are there any particular areas your child needs direction or training in? _________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Is your child a registered member of The ZONE after school program? ¨Yes ¨No
Does your child have any previous camp experience? ¨Yes ¨No
If yes, where? ________________________________________________When? ____________________________________
T-Shirt Size (check one):
¨Youth S
¨Youth M
¨Youth L
¨Adult S
¨Adult M
¨Adult L
SUNSCREEN PERMISSION
Type of sunscreen used: __________________________________________________________________________________
Is staff permitted to help your child apply sunscreen? ¨Yes ¨No
Will you provide your own sunscreen? ¨Yes ¨No
Are you willing to put on sunscreen before coming to camp? ¨Yes ¨No
Do you give camp permission to use our sunscreen (generic brand) on your child? ¨Yes ¨No
**Campers are encouraged to bring hats to outside activities
Parent Signature: ____________________________________________________________ Date: ____________________
The EPICENTER at Edgewood | 1918 Pulaski Highway, Edgewood, MD 21040 | 443-981-3742
CAMP APPLICATION
CAMPER HEALTH HISTORY
(Required for camper to be admitted to day camp. Complete for each camper. Medical forms available upon request.)
Camper’s Name: __________________________________________________________ Date of Birth: ________________
CAMPER IMMUNIZATION INFORMATION
All campers must be current on all immunizations, see www.EDCP.org (immunization).
Date (month & year) of camper’s last tetanus (or DTP) shot: ____________________________________________________
Is the camper currently enrolled in a Maryland school, public or private?
¨Yes: Provide name of Maryland school: ________________________________________________________________
¨
N o: Provide a copy of immunizations confirming that the child has received all immunizations as required by the Maryland DHMH Recommended Childhood Immunization Schedule. See www.EDCP.org (immunization) for information.
Is the camper exempt from any immunization on medical or religious grounds?
¨
Yes: Provide a signed copy of Maryland Department of Health and Mental Hygiene immunization is medically contraindicated, or the parent or guardian indicating that they object to immunizations for religious reasons.
¨No
CONTACT INFORMATION
Parent or Legal Guardian: ____________________________________________________Phone: _____________________
Emergency Contact Person: ___________________________________________________Phone: _____________________
Camper’s Physician: __________________________________________________________Phone: _____________________
HEALTH INFORMATION
Provide information on any medical conditions. Psychological conditions, behavioral conditions, medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Parent Signature: ____________________________________________________________ Date: ____________________
The EPICENTER at Edgewood | 1918 Pulaski Highway, Edgewood, MD 21040 | 443-981-3742
CAMP APPLICATION
ALLERGY & MEDICATION NOTICE
(Complete for each camper)
Camper’s Name: __________________________________________________________ Date of Birth: ________________
My child has allergies/allergic to: _________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Special concerns & needs of my child: _____________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Medications & process for administering medication: _________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Does your child have an inhaler, epi pen or other self-administration medication?
¨
Yes: In order for your child to self-administer we need a doctor’s note with specific instructions. Your child will be supervised by a CAMP EPIC staff member while self-administrating. If medication is to be administered during camp then a
physician order must be attached (can be obtained from doctor’s office)
¨No
Parent Signature: ____________________________________________________________ Date: ____________________
The EPICENTER at Edgewood | 1918 Pulaski Highway, Edgewood, MD 21040 | 443-981-3742
CAMP APPLICATION
TRANSPORTATION
The EPICENTER at Edgewood and Camp Epic are happy to offer transportation from home to The EPICENTER, and back
home each day, for a nominal fee. Campers will not be permitted to ride the van until this form is completed.
Parents wishing to utilize this service must complete the form below and pay $15 per week, for each Camper enrolled,
before transportation can begin. Campers must be enrolled in “Camp Epic” at The EPICENTER at Edgewood.
If parents have any questions, please do not hesitate to contact:
Allison Jefferson
Camp Director of Camp Epic
(443) 981-3742
¨Yes! My child has permission to be picked-up by The EPICENTER beginning (date): ________________________________
Camper’s Name: ___________________________________________________________ Grade: _____________________
Address: ______________________________________________________________________________________________
City: ______________________________________________________________________
Zip: ______________________
Parent Name (please print): _______________________________________________________________________________
Parent Signature: ____________________________________________________________ Date: ____________________
The EPICENTER at Edgewood | 1918 Pulaski Highway, Edgewood, MD 21040 | 443-981-3742
CAMP APPLICATION
PARENTAL CONSENT AGREEMENT
By registering my child I agree to adhere to the following statements:
1. Campers must be between the ages of 5 and 14 years of age to attend camp.
2. The camper and parents/guardians agree to abide by the rules and regulations set by the Director for the health,
safety, and welfare of the campers.
3. I consent to emergency medical care for my child(ren).
4. I consent to have my child(ren) transported to and from day camp on a daily basis and on field trips.
5. I give permission for my child to participate in special programs and activities including field trips and other camp
related activities.
6. I am the legal guardian of the camper listed above and give permission for such camper to attend Camp EPIC at the
Edgewood Community Support Center, Inc. (E.S.C.S.) dba, The EPICENTER at Edgewood, hereinafter “The EPICENTER”.
I understand that my child will be exposed to the Bible and the good news of Jesus Christ. Further, I hereby authorize representatives for The EPICENTER, when I am not present with my camper to consent for all reasonable and
necessary medical and/or surgical treatment and procedures which are required for the above mentioned camper.
I understand that in such an emergency, reasonable attempts would first be made to contact me, time and conditions
permitting, and that in any event, I will be notified of any action taken as soon as reasonably possible. I release The
EPICENTER and any other parties acting on behalf of The EPICENTER from liability in case of an accident. I also
give permission that the Camp EPIC staff carry out any discipline necessary in cases of behavioral misconduct; and
if necessary, I will pay the expense of my son/daughter being sent home.
7. I understand that there may be occasions when The EPICENTER will want to use photographs or audio or video
recordings from activities or events in which my child participates. I grant to The EPICENTER the right to include
photographic, video, audio and other visual or audio portrayals of my child taken during or in connection with The
EPICENTER activities or events in any medium of any nature whatsoever (including the right to edit, combine with other
materials or create any type of derivative thereof) for the purpose of advertising, publicity, promotions, or otherwise,
without compensation to me or my child. Such grant shall include the unrestricted right to copy, revise, distribute, and
display photographs, images, films, tapes, drawings or recordings in any type of media (including, but not limited
to, the Internet). I consent to the use by The EPICENTER of my child’s testimonial, comments and/or narrative writing
in any manner, free of charge, in any form or media. I understand the wording of any testimonial, comments and/or
narrative writing may be edited or altered, provided that the sense and meaning are not materially changed. I agree
that all rights, title and interest therein shall be The EPICENTER’s sole property, free from any claims by me or my child
or any person deriving any rights or interest from me or my child. I release The EPICENTER and its agents and assigns
from any and all claims which may arise out of or are in any way connected with such use.
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The EPICENTER at Edgewood | 1918 Pulaski Highway, Edgewood, MD 21040 | 443-981-3742
CAMP APPLICATION CONTINUED…
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8. I agree to attend a parent meeting on May 30 at 10am or the make up meeting on June 13 at 10am.
9. In case of an emergency, the following person(s) may be contacted and are authorized to pick my child(ren) up
from camp:
Contact #1
Name: __________________________________________________________________________________________
Telephone: ____________________________________________ Relationship: _____________________________
Contact #2
Name: __________________________________________________________________________________________
Telephone: ____________________________________________ Relationship: _____________________________
Contact #3
Name: __________________________________________________________________________________________
Telephone: ____________________________________________ Relationship: _____________________________
Parent Signature: ____________________________________________________________ Date: ____________________
The EPICENTER at Edgewood | 1918 Pulaski Highway, Edgewood, MD 21040 | 443-981-3742