Please complete each section and return with the registration form. Please provide as much details as possible to help ensure a successful summer for the camper.
**For all campers over the age of 21 a prescription is required for assistive devices. If the camper participates in another Arc of Essex County service we will obtain that prescription from the program.
For New and Returning Campers
Emergency Contact Information (different than the Parent/Guardian listed on the Registration Form)
To be completed for all campers that will be utilizing transportation provided by Camp Hope. A copy of this form will be given to the bus company.
I, Your Name* hereby give The Arc of Essex County, Inc. (“The Arc”), Camp Hope (“Camp”) and the Transportation Company (not owned/managed by The Arc of Essex County) permission to provide or arrange necessary related transportation for my child/family member.
Camp Hope Photo Release
THE ARC OF ESSEX COUNTYPhotographs of campers may be taken and used for publicity purposes including but not limited to: publications in commercial periodicals; The Arc of Essex County newsletters and social media; The Arc of Essex County website; and various print, internet, and media publications of The Arc of Essex County.
Photo releases will remain in effect, unless the Arc of Essex County is notified in writing.
THE CANDLE LIGHTERSEstablished in 1974, The Candle Lighters is a 501(c)3 organization dedicated to raising funds for The Arc of Essex County. Camp Hope is one of the organization’s primary beneficiaries. To aid in these efforts, the organization may request the use of camp photos.
Photographs of campers may be taken and used for publicity purposes including but not limited to: publications in commercial periodicals; The Candle Lighters newsletters and social media; The Candle Lighters website; and various print, internet, and media publications of The Candle Lighters.
Authorization for Disclosure of Health Information (HIPAA)
I understand that the above named individual is using the services provided by The Arc of Essex County and The Arc of Essex County may require information from other agencies, providers, school districts or individual’s in order to provide services. I also consent for The Arc of Essex County and the following designated agencies, school districts or individuals to disclose and communicate to one another information and records in their possession which relate to services and or treatment provided for the above named individual:
300 Horizon Drive, Suite 306 Robbinsville, NJ 08690
I understand I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance on this authorization. The request to revoke this authorization must be provided to the Chief Executive Officer at 123 Naylon Ave., Livingston, NJ 07039. The revocation will be effective the date the Chief Executive officer receives it.
I understand that I may refuse to sign this authorization. However, refusal to sign may limit The Arc of Essex County’s ability to obtain information required to assess the support needs and/or services. I also understand that I may inspect and/or copy any written information used or disclosed under this authorization.
This authorization expires on blanks or one (1) year from the date of the individual's or legal guardian's signature.
Camp Hope and The Arc of Essex County reserve the right to release any camper from the Camp Hope program if, after a trial period, The Arc feels that it is not in his/her best interest to remain in the programInitials* RELEASE: I, Full Name* , hereby release The Arc of Essex County, Camp Hope, and its employees of any responsibility or liability for any injury and/or illness derived from participation in the Camp Hope program. I acknowledge the conditions set forth above and agree with their contents in their entirety. Initials of parent or guardian. Initials* I, Full Name* , hereby give permission for my camper to participate in any off site field trips which are part of the day camping program. Initials* I, Full Name* , hereby give The Arc of Essex County, Inc. (“The Arc”), Camp Hope (“Camp”) administration, and the medical personnel selected by the Camp Director (or his/her designee) permission to order X-rays, routine medical tests, and medical treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child, the below identified camper. I understand that the Camp will make reasonable attempts to communicate with me prior to medical treatment in non-life threatening and other non-emergency situations, but that in accordance with the preceding paragraph, medical examination and treatment will be performed without necessarily communicating with me first or in life threatening and other emergency situations, even without attempting such communication. I give consent for transportation to a medical facility (by ambulance or school vehicle) in the event of an emergency. I understand that the permission I have given by signing this form is a material inducement to acceptance of my child as a camper. I also confirm that I have given the Camp and The Arc of Essex County a complete and accurate medical history of my child. Initials*