JVC Summer Camp Application Form

Juniper Valley Summer Camp

June 9- July 17 6 Week Day Program for Individuals with Disabilities Ages 13-17
Participant's Full Name*

First NameLast Name
Participant's Birth Date*

MonthDayYear
School*
Guardian's email*
Current School*
Medication Allergies*
Food Allergies*
Medical Diagnosis (Select all that apply)*
Tshirt Size*
2. Transportation

Parents are solely responsible for coordinating safe and reliable transportation to and from our day camp facilities, with special attention to our Thursday activity schedules. We strongly encourage families to proactively communicate any unique transportation requirements or potential challenges with our camp staff well in advance of the program start date. Our team is committed to supporting parents, to the best of our ability, in ensuring a smooth, stress-free transportation experience that prioritizes the safety and convenience of every camper.
3. Our Volunteers

At Juniper Valley Community, we believe that our volunteers play a vital role in creating a safe, fun, and enriching environment for all campers. Here’s what you need to know about our dedicated volunteers:
- Our volunteers come from diverse backgrounds, including high school students, college students, and community members. Each volunteer is passionate about working with children and is committed to fostering a positive camp experience.
- All volunteers undergo a thorough screening process, including background checks and reference checks, to ensure the safety of our campers. Additionally, they participate in comprehensive training sessions that cover child safety, camp policies, and activity facilitation.
- Volunteers assist in various capacities throughout the camp, including: Leading activities and workshops, providing supervision during recreational times, supporting campers with special needs.
4. Requirements

The child named above is in good health and has no physical or medical limitations that can impact their participation in camp activities. It is important that parents/guardians disclose allergies, medical diagnosis in the section above.
5. Consent

I hereby attest that I am (we are) the legal parent\guardian(s) of the above-named child and hereby consent to the child's participation in the camp activities. I understand that activities of the kind may result in physical injury to my child but nonetheless specifically request that he or she be allowed to participate in those activities.
6. Insurance

I/We understand that Juniper Valley Community does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my own insurance carrier; or (b) that I/We am personally financially responsible for any and all medical costs incurred as a result of the child's injury.
7. Emergencies

If the above-named child requires any emergency medical treatment or procedures during the activities, I hereby consent to and authorize the operating personnel of Juniper Valley Community to make any decision and take any action to arrange for such procedures or treatments in the discretion of the activity supervisor(s).
8. Release and Identification

I release and waive, and further agree to indemnify, hold harmless or reimburse Juniper Valley Community, the individual members, agents, employees and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses, damages or injuries arising out of, during, or in connection with the child's participation in the activities & camp related (including all forms of transportation) or the rendering of emergency medical procedures or treatment, if any.
Parent/ Guardian Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mom's E-mail*
Dad's E-mail*
Home Phone Number

Area CodePhone Number
Mom's Cell Phone Number*

Area CodePhone Number
Dad's Cell Phone Number*

Area CodePhone Number
9. Emergency Contacts

If, in the event of a medical or other emergency, I am unable to be reached by telephone at my home or work telephone numbers listed below, I authorize the activity supervisor(s) to attempt to contact me through the emergency contacts listed below.
Emergency Contact#1 Name*

First NameLast Name
Relationship*
E-mail*
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Emergency Contact#2 Name*

First NameLast Name
Relationship*
E-mail*
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
I, the parent/guardian, hereby attest that I have carefully read this Permission to Participate, understand its contents, and agree to its terms and conditions.*

I agree
Signature*

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Date*

MonthDayYear
Date

JVC Summer Camp Cost & Financial Agreement
Participants Full Name*

First NameLast Name
The Financial Policy for Juniper Valley Community is as follows:

Our organization is a non-profit outreach dedicated to providing summer day camp experiences for individuals with disabilities. We operate independently and sustainably, securing all necessary funds for program materials & equipment, special activites, food services, technology, HR (background checks, training, etc), camper apparel, etc.

Registration fee is $400.00 (Due by May 2, 2025)
We do not offer refunds for the following circumstances: late arrivals or early departures, family vacations during scheduled summer camp days, withdrawal of summer camp, illness, personal emergencies, transportation issues, uncontrollable weather events (severe storms or natural disasters), and force majeure event.

Payments can be made by Check/Money Order, online through your email, or via the registration payment link (A transaction fee may be added to your account if you pay online.)
All return checks are subject to a $20.00 charge.

Your participant’s account must be paid in full by May 2, 2025. If there is a remaining balance your child cannot participate in JVC summer camp.
I, the parent/guardian, hereby attest that I have carefully read this Financial Agreement, understand its contents, and agree to its terms and conditions.*

I agree
Signature*

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Date*

MonthDayYear
Date

Health Policy Acknowledgement
Participant Full Name

First NameLast Name
In efforts to do the best we can for the safety of the Volunteers and the Campers of JVC, Leadership individuals are continuing to stay up-to-date with the latest state and local guidelines and the CDC guidelines regarding the health and safety of your child. We appreciate the trust you place with JVC and commit to following the health and safety requirements and guidelines put in place.

Schools have implemented enhanced procedures to help limit the spread of COVID-19 and other communicable disease, communal infection or illness.

The American Academy of Pediatrics and the CDC states that the 2 best means of stopping the spread of communicable disease or infection are:

1.     Washing your hands frequently

2.     Staying home when you are sick

To maintain a healthy environment at the school during this time of concern, we will be strictly enforcing our Health Guidelines and Protocols. For your convenience, we have outlined them below:

Camper may not attend summer camp if they are sick &/or have a fever (have any communicable disease or communal infection)
Parents are to inform JVC if their child has a contagious disease or is going to be absent.
Children may not attend if they have flu-like symptoms, vomiting, diarrhea, thick yellow-green discharge from the nose, persistent coughing, undiagnosed rash, lice, or other signs of illness
If your child becomes ill during the school day or has a fever of 100.4F, you will be notified. Prompt arrangements for picking up your child in these instances are expected as soon as possible.
Children with a fever cannot return until child has been fever free, without medication for 24 hours
In returning to JVC Summer Camp, your child's temperature may be taken at the discretion of the JVC, if needed
As always, the safety of your children are of utmost importance to us. By adhering to these guidelines we feel we can limit the exposure of unwanted infection here at school.

ACKNOWLEDGMENT

I acknowledge that the participation in Juniper Valley Community Summer Camp involves risk to my child, and may result in various types of illness including, but not limited to, the following: sickness, exposure to infectious/communicable disease and injury in child play. In consideration for the opportunity for my child to participate in JVC Summer Camp, I acknowledge and accept the risks of contracting illness or injury in child play. I accept personal financial responsibility for any injury or other loss sustained during the current school year, as well as for any medical treatment needed that is authorized by JVC. Further, I will not hold Juniper Valley Community liable for any injury or illness arising directly or indirectly in participation of Juniper Valley Community Summer Camp.
Signature*

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Parent/Guardian Full Name*

First NameLast Name
Date*

MonthDayYear
Date

Media Release Form
Participants Full Name*

First NameLast Name
As we seek ways to promote and advertise our non-profit organization, we are asking for your permission to use photographs of the campers as they are involved in summer activities. We would like to use these pictures of our JVC Camp social media, website, slideshows and videos and on rare occasion the local newspaper. It is our goal to secure your parental consent before any camper's picture is used on any form of public media. Please feel free to ask if you have any questions.

This media release may include, but not limited to copyright, personally identifiable information about the above-named individual including photographs, video, name, school of attendance, academic achievements and/or art works for publication, advertising or other lawful purposes including but not limited to publication on any Juniper Valley Community Web page(s) or Social Media Page(s) & printed school media.

I understand that this information might be published on the Internet and therefore published worldwide.
I, the parent/guardian, hereby attest that I have carefully read the Bathroom Consent, understand its contents, and agree to its terms and conditions.*

I agreeI do not agreeOther
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Date*

MonthDayYear
Date

Electronic Signature Agreement
By signing my Full Name, I agree that all the information listed is accurate and I have authorized permissions for all the included information on this form. I also agree that if there are any changes to this information during the summer camp dates, I will contact the Juniper Valley Community Team as soon as possible.
Signature*

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Parent/ Guardian Full Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Juniper Valley Summer Camp

2. Transportation

3. Our Volunteers

4. Requirements

5. Consent

6. Insurance

7. Emergencies

8. Release and Identification

9. Emergency Contacts

JVC Summer Camp Cost & Financial Agreement

Health Policy Acknowledgement

Media Release Form

Electronic Signature Agreement