Day Sessions / Camp Application / 2023

We know that raising a child with mental, emotional, and behavioral health challenges can feel overwhelming. At Camp Get-A-Way, we regularly see families, who come to camp feeling discouraged and isolated, leave feeling refreshed, connected and equipped after spending time with other families facing similar challenges.

Our day camps will offer your family the opportunity to learn new skills in an encouraging and supportive environment. You will learn some skills and do some activities together to learn from each other and practice as a family. You will also learn some skills separately to give children and parents the ability to discuss things more openly than they might together.

Try new activities together, form friendships with others who understand, and receive specific skills training that you can practice in the moment and use when you return home. In addition to this, we’ll provide you with breakfast, lunch, dinner, and even s’mores around a campfire.

Have questions? Contact us at hello@cgaw.org.
Date

MonthDayYear
Date
family information
Family Name*
Name of adult completing this application *

First NameLast Name
Primary Language*
Number of adults (18+) attending camp (Note: At least one adult must attend the entire day session with the child/children)*
Number of children attending camp*
Which session do you wish to attend? You may only check one camp session. Every effort will be made to accommodate the desired session; applications are processed on a first-come basis based on completion and payment received.*

September 25, 2023 at Camp Bristol Hills in Canandaigua, NYOctober 9, 2023 at Wyoming County Ag and Business Center in Warsaw, NYOctober 20, 2023 at Camp Bristol Hills in Canandaigua, NYNovember 10, 2023 at Wyoming County Ag and Business Center in Warsaw, NYNovember 17, 2023 at Camp Stella Maris in Livonia, NYNovember 29, 2023 at Camp Stella Maris in Livonia, NY
Adult #1 (Adult completing camp application)*

First NameLast Name
Date of Birth*

MonthDayYear
Relationship to Child*
Email (a majority of contact will be via email)*

Confirmation Emailname@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone*

Area CodePhone Number
Type of Phone*

MobileHome
Food Allergies*

Adult #2*

First NameLast Name
Date of Birth*

MonthDayYear
Relationship to Child*
Email*

Confirmation Emailname@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone*

Area CodePhone Number
Type of Phone*

MobileHome
Food Allergies*
While multiple adults are welcome to participate in the camp session, Camp Get-A-Way requires that at least one adult commit to participating in the entire day session. Please check to acknowledge you understand this requirement.*

yes, I understand
Name of one adult who will remain for the entire day session with the child/children

First NameLast Name

Child #1*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Child Age*
Food Allergies*
Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
Phone (if you want to provide)
Email (if you want to provide)

Child #2*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Child Age*
Food Allergies*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #3*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Child Age*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #4*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Child Age*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

safety, concerns, and needs

These questions are asked not as a rule out for acceptance to CGAW, but so that we can better serve each and every member of your family, as well as provide for the safety and well being of all campers. Please identify all areas (past or present) that apply for EACH member of your family attending camp this year.
Poor self care
If so, please identify which family members above.
Violent/aggressive behavior
If so, please identify which family members above.
Cruelty to animals
If so, please identify which family members above.
Stealing
If so, please identify which family members above.
Fire setting
If so, please identify which family members above.
Conviction of a crime
If so, please identify which family members above.
Self harming
If so, please identify which family members above.
Drug and alcohol
If so, please identify which family members above.
Delusional thoughts
If so, please identify which family members above.
Runaway/leave without permission
If so, please identify which family members above.
Sexual acting out
If so, please identify which family members above.
Suicidal/homicidal ideation
If so, please identify which family members above.
Restraining order
If so, please identify which family members above.
Order of protection
If so, please identify which family members above.

consents, disclaimers, and releases
Confidentiality Statement (required)

The Camp Get-A-Way team agrees to treat knowledge of any confidential information in a secure manner and to use the information only for the purpose for which it was shared. It is Camp Get-A-Way’s belief that what is talked about and shared during the camping experience among participating families and staff will remain confidential after families and staff returns to their homes.

Family members covered by this consent:
- {adult13}
- {adult2143}
- {child1}
- {child2}
- {child3}
- {child4}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear
Liability Disclaimer (required)

I, {adult13}, hereby release Camp Get-A-Way, its officers, volunteers, and family participants from any liability that might occur while participating in the programs offered during my time at Camp Get-A-Way.

Family members covered by this consent:
- {adult13}
- {adult2143}
- {child1}
- {child2}
- {child3}
- {child4}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear
Consent for Taking and Releasing Photographs and Video (optional)

I, {adult13}, give consent to the taking of photographs and/or video either arranged by or taken by Camp Get-A-Way. I give this consent and release to use my photographic likeness in all forms, media, and any other lawful purposes for the advancement of Camp Get-A-Way.
Family members covered by this consent:
Family members NOT covered by this consent:
Signature*
Date

MonthDayYear

support team
My family is supported by a (check all that apply):

Community Mental Health ProviderFamily Support ProgramN/A

community mental health provider
Provider Name*

First NameLast Name
Agency*
Provider Email*

Confirmation Emailexample@example.com
Provider Fax Number*

Area CodePhone Number
Provider Phone Number*

Area CodePhone Number
Consent for Release and Exchange of Information with Community Mental Health Provider:

This consent will be in effect November 10, 2020.

I, {adult13}, give consent to Camp Get-A-Way to release and exchange information with my community mental health provider listed below:

Provider Name: {providerName}
Agency: {agency}
Provider Email: {providerEmail}
Provider Fax: {providerFax}
Provider Phone: {providerPhone}

_______________________

Family members covered by this consent:
- {adult13}
- {adult2143}
- {child1}
- {child2}
- {child3}
- {child4}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear

family support program
Provider Name*

First NameLast Name
Family Support Program*
Provider Email*

Confirmation Emailexample@example.com
Provider Fax Number*

Area CodePhone Number
Provider Phone Number*

Area CodePhone Number
Consent for Release and Exchange of Information with Family Support Program:

This consent will be in effect November 10, 2020.

I, {adult13}, give consent to Camp Get-A-Way to release and exchange information with {familySupport} Family Support Program

Provider Name: {providerName263}
Agency: {familySupport}
Provider Email: {providerEmail265}
Provider Fax: {providerFax266}
Provider Phone: {providerPhone267}

_______________________

Family members covered by this consent:
- {adult13}
- {adult2143}
- {child1}
- {child2}
- {child3}
- {child4}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear

expectations of camp get-a-way
Camp Get-A-Way has developed the following basic list of expectation to ensure a safe, healthy, and fun camping experience for everyone involved. Any violation of these rules may result in a family’s dismissal from Camp Get-A-Way. All concerns will be reviewed by the Board and all decisions made are final.
- Children are the sole responsibility of their parents/guardians at all times.
- No child of any age can be unsupervised at any time.
- Parents / guardians must know where their children are at all times.
- All children 15 years old and younger must have direct adult supervision at all times.
- Children 16 years old and older: Must be in direct visual contact of an adult at all times.
- Parent/guardian will be responsible for any damage or destruction caused while at camp.
- Smoking is allowed only in designated area(s) of camp. Anyone smoking in non-designated areas will be asked to leave Camp. Absolutely NO smoking in or around the cabins. Children are not allowed in the smoking shelter.
- No possession or consumption of illegal drugs, or being under the influence of illegal drugs is allowed in camp.
- No alcohol, alcohol consumption, or being under the influence of alcohol is allowed while at camp.
- No weapons are allowed in camp.
- No stealing.
- No physical or verbal aggression towards others.
- No one may leave camp while camp is in session without signing in and out at Nurses Station.
- All medications MUST BE IN THEIR ORIGINAL CONTAINERS (prescription and over the counter, with certain exceptions) and will be locked in the Nurse’s Cabin at all times.
- No swimming without lifeguard on duty. Waterfront Activities require direct adult supervision for all camp participants.
- Campfires only in designated area.
- All family members are expected to participate in family activities, camp upkeep, and dining hall chores.
- Quiet time is from 10:00pm until 7:30am.
- Families are encouraged to keep a copy of the rules, which will be posted throughout camp and are available on the Camp Get-A-Way website.
It is very important that everyone understands the expectations before arriving at Camp Get-A-Way. The expectations are to ensure the safety of all campers, volunteers and staff. By signing below, we acknowledge that we have read and reviewed this with all family members that will be attending and received a copy of the expectations of Camp Get-A-Way.
Print name of signer #1*

First NameLast Name
Signature #1*
Date*

MonthDayYear
Print name of signer #2

First NameLast Name
Signature #2
Date

MonthDayYear
Print name of signer #3

First NameLast Name
Signature #3
Date

MonthDayYear
Print name of signer #4

First NameLast Name
Signature #4
Date

MonthDayYear

APPLICATION FEE

Day Session Application Fee$25.00

Quantity

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

family information

safety, concerns, and needs

consents, disclaimers, and releases

support team

community mental health provider

family support program

expectations of camp get-a-way