As of 12/14/23 - CAMP IS NOW FULL
You may continue to apply and you will be placed on the waiting list. We will reach out to you if a space becomes available. Thank you
Camp Dates: December 27-31, 2023 Camp Location: Glendale, AZ For boys (Ages 9-12)
Age as of December 1, 2023
There is NO cost to attend Run Home Camps. Applicants will be processed on a first-come, first-served basis until the camp is full. If the camp is full we will contact you and ask if you would like to be on the waiting list.
IF YOU HAVE QUESTIONS about available space, if your child qualifies for camp, or have other questions or concerns about Run Home Camps (Also referred to as RHC below): Please contact Mike McCullough at firstname.lastname@example.org or 602-570-7606
TIME TO FILL OUT APP: Will take 30-40 minutes. Please fill out ENTIRELY. One application per child.
Preferred Name (if child has one)
Please select a month
Please select a day
Please select a year
Child's T-Shirt Size
Siblings of Child Applying to RHC
If siblings of this child will ALSO be applying to Run Home Camps, please provide their info so we can try and get all siblings to camp as well. PLEASE NOTE THAT A SEPARATE APPLICATION IS REQUIRED FOR EACH CHILD that is applying to camp.
Please enter any siblings names that will also be filing out an application for Run Home Camp. Please include relationship
Name of Person Filling Out This Application
Relationship To Child
This home is best described as...
Home for Unaccompanied Refugee Minor
If this child was adopted, when was he adopted?
Date Picker Icon
Approximately when was this child placed in the current home?
Date Picker Icon
Total # foster or residential placements for child including current home.
Mailing Address (for camp correspondence)
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Parent or Legal Guardian #1
Relationship to Child
Best Phone Number
This phone is a:
Parent/Guardian #1 Email Address
Parent or Legal Guardian #2
Relationship to Child
Parent or Legal Guardian #2 Best Phone Number
This phone is a:
Parent/Guardian #2 Email Address
Authorized to Pick Child Up
Run Home Camps will only release the child to one of these individuals at the end of camp
FIRST adult authorized to pick up this child from camp **Government ID required**
Cell Number for Authorized Adult #1
SECOND adult authorized to pick up this child from camp **Government ID required**
Cell Number For Authorized Adult #2
Caseworker/Child Placement Agency Information
Child Placement Agency (Current or Past if Child Has Been Adopted)
Caseworker Phone 1
Caseworker Phone 2
CASA (Court Appointed Special Advocate) if child has one
CASA Phone Number
Please fill this out to the best of your ability. We as RHC staff want to make sure your child has a safe, healthy, fun time at camp. This information is extremely helpful!
Why would this child's attendance at RHC be important? Why would you like to see him attend camp?
How often does this child wet the bed at night?
If child does wet the bed, please explain (i.e. wears pull-ups, don't drink liquids after certain time, just need to be aware, etc.)
Does this child display aggressive behavior?
Please explain aggressive behavior. (What may trigger aggressive behavior or to whom child is aggressive.)
Does this child bite other children or adults?
Does the child deal with any of the following eating disorders or issues around food?
No Eating Disorders
Do Not Know Of Any Eating Disorders
Hording or Stealing Food
If this child does have an eating disorder - or has other issues around food we should know about - please explain.
Would you describe this child as hyperactive?
Please let us know if any of the following learning difficulties exist for this child.
Vision impairment (that would affect time at camp)
Dyslexia or reading difficulties
Don't know about learning difficulties
If these learning difficulties will negatively affect this camper's week at camp - or if this information would help Staff make camp better for your child - please explain.
How often does your child lie?
If this child does have a habit of lying, please explain.
Please let us know how often your child has nightmares.
Please let us know how to calm your child or prevent nightmares.
Please let us know how often this child runs away from a situation or from home.
If this child does run away, please explain what calms him down or what triggers running away.
Please let us know often this child may act out sexually.
If this child does act out sexually, please explain.
How often does this child steal things?
If this child does steal or take things, please explain.
How often does this child have tantrums or anger issues?
If this child does have tantrums or anger issues that are beyond normal childhood frustrations, please explain so we know how to redirect or prevent outbursts.
How often does this child withdraw?
If this child is withdrawn (or certain circumstances cause this), please explain.
HISTORY/STORY: Please share this child's history or story so we can understand how to give him an even MORE amazing week at camp!
** Please tell us about this child's history or story. What situations may have been challenging for this child? What circumstances is this child dealing with?
Please tell us what this child's interests, passions, loves, etc. are so our Staff can make camp even more special! (i.e. Loves sports, interested in science, favorite color is blue...whatever!)
Any additional information you need for our staff to know while your child is at camp?
REQUIRED: Please take a picture of the front AND back of child's Medical Card (or Insurance) and upload here
List all known allergies to food, plants, medications, animals, etc.
Date of Last Physical
Date Picker Icon
What specific activities should we encourage your child to try while at camp?
Illnesses and Medical Complications Past or Present (check all that apply)
Topical Allergies (lotion, sunscreen, etc.)
Dizzy Spells and/or Fainting
ADD or ADHD
Heart or Circulation Problems
Poison Oak/Poison Ivy Allergies
Type 1 Diabetes (previously insulin-dependent)
Type 2 Diabetes (previously non-insulin dependent)
Insect Bite Allergies (i.e. mosquitoes, bees, wasps, etc.)
Recent Broken Bones
Please explain each medical issue you checked above. (If you did not check anything, please type "N/A".
Prescription & Over-the-Counter Medications
If your child is NOT taking any prescription or over-the-counter medications, vitamins, or inhalers to camp, please type "NONE" in each of the boxes for Medication #1.
I understand that it is my responsibility as a caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp for December 27-31, 2023. I authorize RHC medical staff to administer the medications.
Yes, I understand that sharing medical info, medications, and dosages are my responsibility and I grant authorization to administer the medications.
** Only check Medications that are APPROVED**
ALLOWED Medications / Treatments: Check ONLY those you APPROVE the camp medical team to administer...
Tylenol or Advil
Please explain why you said NO to the medications that are UNCHECKED above. (If you did not uncheck any, just type "N/A")
What specific activities should be DISCOURAGED for medical reasons while at camp?
Prescription or Over-the-Counter Medication #1
Prescription Medication 1: Reason for taking, DOSAGE, and Time(s) of Day to Administer
How long as child been taking Medication 1? (Be specific.)
Prescription or Over-the-Counter Medication #2
Medication 2: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long has child been taking Medication #2? (Be specific.)
Prescription or Over-the-Counter Medication #3
Medication 3: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long as child been taking Medication #3? (Be specific.)
Prescription or Over-the-Counter Medication #4
Medication #4: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long as child been taking Medication #4? (Be specific.)
Prescription or Over-the-Counter Medication #5
Medication #5: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long has child been taking Medication #5? (Be specific.)
Additional information we need to know about the above prescription drugs, vitamins, or over-the-counter medications sent to camp - or - additional meds if any.
Physician, PA, or NP for Child
Physician, PA, NP, or Clinic Phone Number
Any immunizations the child has NOT RECEIVED or NOT UP TO DATE please explain, otherwise type "N/A"
Parent/Guardian Permission and Liability Release
I certify that I am the parent or legal guardian of this child
Yes, I am the parent or legal guardian of this child.
I recognize that there may be occasions where the named participant may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health conditions or injury. I do hereby give permission for agents of Run Home Camps to seek and secure any needed medical attention or treatment for the named participant including hospitalization, if in the agent’s opinion such need arises. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.
Yes, I give my permission and accept responsibility for medical treatment.
It is my understanding that participating in the programs and recreational and other activities of Run Home Camps is a privilege. I expressly warrant that I am a legal guardian of the named participant and that he has my permission to participate in all of the activities during the duration of the Run Home Camps including any required transportation. Prior to named participant’s participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.
Yes, i understand the risks of participating in camp and I grant permission for my child to do so.
By checking this item I expressly warrant that I am a legal guardian of the named participant and that he is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of named participant’s participation in the activities, whether such risks are known or unknown to me at this time. I further release Run Home Camps and its leaders, employees, volunteers, and agents from any claim that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of my family or estate, heirs, representatives, or assigns may have against Run Home Camps or its leaders, employees, volunteers, or agents.I further agree to indemnify and hold harmless Run Home Camps and its leaders, employees, volunteers, or agents from any and all claims arising from named participant’s participation in its activities and programs, or as a result of injury or illness during such activities.
Yes, I agree to this release of liability
Submission of a completed application does not guarantee your child a position at camp. One of our staff members will reach out to you to confirm your child's position.
Checklist for this Online Application: Check that you have ALL items needed to complete this application.
ONLINE APP: Completely filled out online RHC application submitted online. (Please do NOT print this application. It is important to have all information stored online and not in paper form.)
MEDICAID/INSURANCE COPY: Uploaded
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