Summer Day Camp 2016 – Benton County
Briarwood Elementary School – Camden, TN
Thursday, June 30, 2016
9 a.m. to 3 p.m.
Thank you for your interest in attending our Benton County Summer Day Camp Session of 8-5-2-1-0
Every Day! Camp. This camp is for students in elementary and middle school, grades 1st through 8th
grade and is focused on simple, guiding principles related to health – 8 hours of sleep, 5 fruits and
vegetables per day, 2 hours or less screen time a day, 1 hour of exercise daily, and 0 sugary drinks or
soda. The curriculum involves fun activities, games and interactive programming that will encourage your
youth to become healthier for life. The program is offered by the Paris and Henry County Healthcare
Foundation, a non-profit 501(c)3, through a federally-funded grant known as the Delta Rural Health
Initiative.
Summer Day Camp is an abbreviated version of our week-long day camp offering a free lunch and camp
activities at Briarwood Elementary School in Camden, TN. Students are asked to be at the gym no later
than 9 a.m. and be picked up from the gym no later than 3 p.m.
APPLICATION PROCESS
Please read the following carefully. Summer Camp enrollment is first come, first served. If you prefer to
apply online, you can find a link to our online at www.hcmc-tn.org, selecting class and events. Though
registering online holds your place, you must return all paperwork to HCMC either via e-mail or fax by
Monday, June 27, 2016.
To apply by mail, please send us the program application to arrive no later than Monday, June 27, 2016.
You can also drop the application off at the HCMC Marketing or Healthcare Foundation offices.
We will notify each applicant regarding enrollment status as soon as possible. Please mark on the
st
th
th
th
application if the student is in elementary school (1 through 4 grade) or middle school (5 through 8
grade). Once your camper is enrolled, we will send you a confirmation email and the return paperwork
packet.
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[PLEASE KEEP THIS PAGE FOR YOUR RECORDS]
SUMMER CAMP PROGRAM SITE
Briarwood Elementary School
CONTACT INFORMATION
Mailing Address: Henry County Medical Center, c/o Marketing Dept., PO Box 1030 or 301 Tyson Ave.,
Paris, TN 38242
Website: www.hcmc-tn.org
Email: [email protected]
Phone: 731-644-8266
Fax: 731-644-8360
WHEN TO SHOW UP AND WHAT TO BRING
Camp is on Thursday, June 30 from 9 a.m. to 3 p.m. with lunch served. Campers should wear
comfortable clothing and close-toed shoes (preferably tennis shoes), and bringing a water bottle is
highly recommended. Please note that if you choose to bring any personal items, Camp cannot be
responsible if they are lost or damaged.
Thank you so much for your interest in Camp -- we look forward to working with you!
Any photos, recorded (audio or video) and written materials created for and/or during Summer Camp are property of Henry County
Medical Center and Paris and Henry County Healthcare Foundation.
The policy and intent of the 8-5-2-1-0 Every Day! Summer Camp 2016 is to provide equal opportunity for all persons regardless of race,
color, religion, national origin, ancestry, marital status, political affiliation, affectional orientation, sex, status with regard to public
assistance, disability, age, veteran status, and any other status protected under federal, state, or local laws. We promote respect and do
not tolerate racism, sexism, homophobia, or other discriminatory behavior or expression.
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8-5-2-1-0 Every Day! Summer Day Camp 2016
Program Application
(Thanks for printing legibly or typing!)
1. CHOOSE AN AGE GROUP
______1st through 4th grade
______5th through 8th grade
2. CAMPER AND PRIMARY CONTACT INFORMATION
Name of Student: __________________________________ Date of Birth: ___________ Age (at the time of Camp): _______
Name you prefer to be called (if different): _________________________________________________
Name of School: _____________________________________________
Grade: _______
T-Shirt Size (circle one): Youth: XS SM MED LG or Adult: SM MED LG XL XXL XXXL
Name of Parent/Guardian/Primary Contact: _________________________________________________________________
Mailing Address: ___________________________________________________________________________
City: ______________________________ State: _______________________ Zip Code: ________________________
Home Phone: _______________________ Cell Phone: _____________________ Work Phone_____________________
Email address you check frequently:______________________________________________________
Best way to contact you? (circle one) Home Phone
_____ Please send my paperwork via US mail
or
Cell Phone
Email
______Please send my paperwork via email
What is the race/ethnicity of you/your camper?* __________________________________
________Prefer not to say
*Knowing the demographic makeup of our campers/community can assist in grant writing, intentional outreach, and more -please respond if you feel comfortable.
3. EMERGENCY CONTACTS (please provide two additional people, different from the parent/guardian listed above,
who would automatically be the first person we contact)
First Contact’s Name: ______________________________________ Relationship: __________________________
Home Phone: _____ - ______ - ______
Work/Cell Phone: _____ -______ - ______ ext ______
Second Contact’s Name: ____________________________________ Relationship: __________________________
Home Phone: _____ - ______ - _______
Work/Cell Phone: _____ -______ - ______ ext ______
4. SAFETY INFORMATION (please list all known conditions so we can accommodate your camper’s
needs)
Does your camper have any medical conditions, allergies, or special needs the staff should know about?
______________________________________________________________________________________________________
_____________________________________________________________________________________________________
Does your camper have any behavioral or emotional issues the staff should know about?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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Is your camper taking any medications to treat these conditions?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
[PLEASE INCLUDE A COPY, FRONT AND BACK, OF YOUR CHILD’S INSURANCE CARD IN CASE
OF NEEDED CARE]
5. OTHER INFO
Is there anything else you would like us to know?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
To complete your application; please send these pages to
8-5-2-1-0 Every Day! Summer Day Camp 2016
c/o Marketing Department
PO Box 1030
Paris, TN 38242
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