Overnight Sessions / Camp Application / 2023

Since 2002, Camp Get-A-Way has been a place where you and your kids can play, connect, create, and bond in the great outdoors. Try new things like archery, swimming, fishing, and canoeing as a family. Share laughter and s’mores by the campfire. Create memories over tie-dye fun, camp crafts, and games. Find hope through family resources and training. And start lasting friendships with other New York families facing similar challenges.

We know life often doesn't feel "normal" when you have a child struggling with an emotional, behavioral, or mental health challenge. That’s why Camp Get-A-Way comes alongside families like yours to create a safe camp experience where families can just be families.

Please be sure to read through the application to be certain you have all the documentation you need. Camp sessions are scheduled on a first come, first served basis. Space is limited. A complete list of eligibility criteria is available by contacting Camp Get-A-Way. Each family member MUST have a medical history form and physical or letter from Doctor office.

2024 SESSIONS:
- May 24-27 • Tully, NY
- August 18-21 • Canandaigua, NY
- Sept. 27-29 • Ithaca, NY
CAMP COSTS:
Camp costs:
- $450.00 per family (for a family of up to five people; $50 per additional person)
- $25.00 non-refundable application fee
- Applications and complete payment are due 30 days prior to the start of the session for which you registered.
TRANSPORTATION:
Due to very limited staff availability, every effort should be made by the family and with their service provider to arrange transportation directly to Camp.

DIETARY NEEDS:
Please include special medically prescribed dietary needs with your application materials and notify CGAW at least one week before camp if anyone’s dietary needs have changed. In addition, other dietary accommodations will be considered on a case-by-case basis with advance notice.

Have questions? Visit cgaw.org/faqs or contact us at hello@cgaw.org.

We look forward to seeing you in 2024!

Sincerely,

Ken Tangel, President
family information
Family Name*
Name of adult completing this application *

First NameLast Name
Primary Language*
Number of adults (18+) attending camp*
Number of children attending camp*
Please check Camp Session you are applying for; show your first and second choice. Every effort will be made to accommodate the desired session; applications are processed on a first come basis based on completion and payment received.*

February 23-25, 2024 (Huguenot, NY)May 24-27, 2024 (Tully, NY)August 18-21, 2024 (Canandaigua, NY)September 27-29, 2024 (Ithaca, NY)

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

Community Mental Health ProviderFamily Support ProgramN/A

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 my 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 my family support program listed below:

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

_______________________

Family members covered by this consent:
- {adult13}
- {adult2906}
- {adult3939}
- {adult4970}
- {child1}
- {child21001}
- {child31026}
- {child41051}
- {child51077}
- {child61102}
Printed Name: {adult13}
Signature*
Date*

MonthDayYear
Date*

MonthDayYear

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 my 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 my family support program listed below:

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

_______________________

Family members covered by this consent:
- {adult13}
- {adult2906}
- {adult3939}
- {adult4970}
- {child1}
- {child21001}
- {child31026}
- {child41051}
- {child51077}
- {child61102}
Printed Name: {adult13}
Signature*
Date*

MonthDayYear
Date*

MonthDayYear

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 behavior
If so, please identify which family members above.
Drug/alcohol problems
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 misconduct
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
Consent for Emergency Medical Care and Emergency Contacts (required)

I, {adult13}, give consent to Camp Get-A-Way to release and exchange information with my family support program listed below:

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

_______________________

Family members covered by this consent:

{adult13}
{adult2906}
{adult3939}
{adult4970}
{child1}
{child21001}
{child31026}
{child41051}
{child51077}
{child61102}
Printed Name: {adult13}
Signature*
Date*

MonthDayYear
Date*

MonthDayYear

in case of emergency...

Please list three people we may contact.
Emergency Contact #1*

First NameLast Name
Relationship to Emergency Contact #1*
Emergency Contact #1 – Phone*

Area CodePhone Number
Emergency Contact #2*

First NameLast Name
Relationship to Emergency Contact #2*
Emergency Contact #2 – Phone*

Area CodePhone Number
Emergency Contact #3*

First NameLast Name
Relationship to Emergency Contact #3*
Emergency Contact #3 – Phone*

Area CodePhone Number

disclaimers
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}
  {adult2906}
  {adult3939}
  {adult4970}
  {child1}
  {child21001}
  {child31026}
  {child41051}
  {child51077}
  {child61102}
  Printed Name: {adult13}
Signature*
Date*

MonthDayYear
Date*

MonthDayYear
Liability Disclaimer (required)

I, {adult1}, 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}
{adult2906}
{adult3939}
{adult4970}
{child1}
{child21001}
{child31026}
{child41051}
{child51077}
{child61102}
Printed Name: {adult13}
Signature*
Date*

MonthDayYear
Date*

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

I, {adult1}, 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
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.
Signer*

First NameLast Name
Signature*
Date*

MonthDayYear
Date*

MonthDayYear

you're almost done!
Billing Contact Name*

First NameLast Name
Billing Contact Email*
example@example.com
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YAY!

If you haven't already, download the Physical Examination Form for your doctor to fill out. This must be completed to attend camp.

DOWNLOAD PHYSICAL FORM →
Should be Empty:

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

family information

your camp experience

adult #1

adult #2

adult #3

adult #4

Child #1

Child #2

Child #3

Child #4

Child #5

Child #6

support team

family support program

community mental health provider

safety, concerns, and needs

consents, disclaimers, and releases

in case of emergency...

disclaimers

expectations of camp get-a-way

you're almost done!

	Medication	X's Per Day	Dosage

	Medication	X's Per Day	Dosage

	Medication	X's Per Day	Dosage

	Medication	X's Per Day	Dosage