2024 Camp HLC Application

1

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

2

Parent/ Guardian 1* This field is required.

First Name

Last Name

Please enter your email

Please enter your phone

Relationship to Camper

Gender

3

I understand that Hope Loves Company may need to contact me via cell about program information. By checking this box I give consent to Hope Loves Company to text me at the above listed number and understand that I may opt out at any time.* This field is required.

I agree and give consent to receive text messages.

I do not agree to receive text messages.

4

Will parent/guardian 1 be attending camp?* This field is required.

YESNO

5

If parent/guardian 1 is attending please provide the information below.

T-Shirt Size

Dietary Restrictions or Allergies

6

Will parent/guardian 2 be attending camp?

YESNO

7

Parent/ Guardian 2

First Name

Last Name

Please enter your email

Please enter your phone

Relationship to Camper

Gender

8

Will parent/guardian 2 be attending camp?

YESNO

9

If parent/guardian 2 is attending please provide the information below.

T-Shirt Size

Dietary Restrictions or Allergies (Food, Environmental, etc.)

10

Emergency Contact * This field is required.Please provide information of a trusted adult not attending camp.

First Name

Last Name

Please enter your email

Please enter your phone

Relationship to camper

12

Who has ALS in your family & what is their relation* This field is required.

pALS First and Last Name

pALS lives or lived in home with camper(s)

Camper is/was an active caregiver to pALS

Caregiver task the camper took place in

13

Is this person currently battling ALS?* This field is required.

YESNO

14

How are they doing? Please explain how your pALS is currently doing.

15

When did they pass away?

Date

16

Military AffiliationThis question is optional. However, it will help us with grant information to help more kids and families affected by ALS.

Child of a veteran or former Uniformed Services member

Child of someone currently serving in US Armed Forces

Spouse of veteran or former Uniformed Service member

Spouse of someone currently serving in US Armed Forces

Uniformed service veteran

Covered veteran under Section 4212

N/A

17

Which camp location would you like to attend?* This field is required.

18

Camper #1* This field is required.

First Name

Last Name

Camper's Email

Camper's Cell Number

Gender

Pronouns

DOB MM/DD/YYYY

Select camp age group based on the age that your camper will be during camp.

19

Camper #1 T-Shirt Size:* This field is required.

20

Camper #1 Dietary Restrictions or Allergies (Food, Environmental, etc.):* This field is required.If there are no restrictions or allergies to provide, please write "N/A".

21

Give a brief description of your child's personality, their likes/dislikes, and any activities they enjoy.* This field is required.

22

Each camper’s experience at camp is somewhat different. Tell us what you hope your child will gain from this experience. What are your goals for them?* This field is required.

23

In what way can the cabin counselor aid your child’s development? * This field is required.(For example: values, confidence, social/emotional skills, friendship, etc…)

24

Other advice or concerns that will help our team support your child this weekend.

25

Please upload a recent photo of Camper #1* This field is required.The photo should include just your child and be clear and close-up.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

26

Do you need to sign up camper #2?* This field is required.

YESNO

27

Camper #2

First Name

Last Name

Camper's Email

Camper's Cell Number

Gender

Pronouns

DOB MM/DD/YYYY

Select camp age group based on the age that your camper will be during camp.

28

Camper #2 T-Shirt Size

29

Camper #2 Dietary Restrictions or Allergies (Food, Environmental, etc.):If there are no restrictions or allergies to provide, please write "N/A".

30

Give a brief description of your child's personality, their likes/dislikes, and any activities they enjoy.

31

Each camper’s experience at camp is somewhat different. Tell us what you hope your child will gain from this experience. What are your goals for them?

32

In what way can the cabin counselor aid your child’s development? (For example: values, confidence, social/emotional skills, friendship, etc…)

33

Other advice or concerns that will help our team support your child this weekend.

34

Please upload a recent photo of Camper #2The photo should include just your child and be clear and close-up.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

35

Do you need to sign up additional camper #3?

YESNO

36

Camper #3

First Name

Last Name

Camper's Email

Camper's Cell Number

Gender

Pronouns

DOB MM/DD/YYYY

Select camp age group based on the age that your camper will be during camp.

37

Camper #3 T-Shirt Size

38

Camper #3 Dietary Restrictions or Allergies (Food, Environmental, etc.):If there are no restrictions or allergies to provide, please write "N/A".

39

Give a brief description of your child's personality, their likes/dislikes, and any activities they enjoy.

40

Each camper’s experience at camp is somewhat different. Tell us what you hope your child will gain from this experience. What are your goals for them?

41

In what way can the cabin counselor aid your child’s development? (For example: values, confidence, social/emotional skills, friendship, etc…)

42

Other advice or concerns that will help our team support your child this weekend.

43

Please upload a recent photo of Camper #3The photo should include just your child and be clear and close-up.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

44

How is your child getting to and from camp?* This field is required.

45

Child Drop-Off and Pick-Up Authorization:* This field is required.Person other than parent/guardian authorized to drop off and/or pick up child. No one will be permitted to pick up your child if their name is not listed here. All persons must have and show their picture ID. This requirement is necessary to account for all campers and to keep them safe.

Name

Cell Phone

Relationship

If selected Other, please type relationship here.

Address (Street, City, State, Zip)

46

Family Travel Assistance There is travel assistance to Camp HLC for children and families who have difficulty getting to camp due to financial restrictions, and/or Camp HLC is unavailable within their geographical area. Travel assistance “awards” and amounts will be reviewed and disbursed on a case-by-case basis. Families accepted for travel reimbursement will be responsible for arranging their travel accommodation. Are you interested?

YESNO

47

Photo & Video ReleasePlease read the following document.

48

Photo & Video Release* This field is required.

I have read and agree to the photo & video release.

49

Confidentiality Policy

50

Confidentiality Policy* This field is required.

I have read and agree to the confidentiality policy.

51

Sexual Abuse Policy and Procedure Agreement

52

Sexual Abuse Policy and Procedure Agreement* This field is required.

I have read and agree to the sexual abuse policy and procedure agreement.

53

Waiver & Release Agreement

54

Waiver & Release Agreement* This field is required.

I have read and agree to the waiver & release agreement.

55

Name of Participants * This field is required.Please list the name all the participants who will be attending camp. These names will be in reference Hope Loves Company, Inc.’s policy on Confidentiality, Sexual Abuse and Procedures, and Waiver &Release Agreement presented above.

56

Signature of Acknowledgement* This field is required.I, the undersigned, acknowledge that I have completely read and fully understand the Hope Loves Company, Inc.’s policy on confidentiality and the Statement of Confidentiality, sexual abuse and the Sexual Abuse Policy and Procedures, and Waiver &Release Agreement presented above. I agree that my signature below is acknowledgement to abide by the requirements of policy and agreements.

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57

Today's Date * This field is required.

Date

58