Camp Hope Campers

Camp Hope Day Camp Registration
Camp Hope campers are invited to participate in Camp Hope Day Camp, a brand new program for youth who have attended Camp Hope; ages 11-17. Camp Hope Day Camp is a positive, life skill training, activities especially designed to ensure success for youth residing in foster care, kinship care, and/or who have an incarcerated parent.

Every youth is offered complete confidentiality. No volunteers will take photos, other than the camp photographer who will take pictures for individual camper photo albums. All Camp Hope promotional videos/pictures will be edited for confidentiality.

Caregivers/Parents can choose which months they want their child to join in on Building Hope activities. This will help us plan events and ensure a smooth and enjoyable experience for all participants. Dates for each component will be listed in the application. If you sign up for a component without a date determined yet, we will email you as soon as we have that information.

If you have any questions please e-mail: Camp Director - Heather Lojeski - hlojeski@fhlforkids.org
Camp Hope

(For ages 11-16 years old)

SECTION 1: Camper Information
Camper's Full Name*

First NameMiddle NameLast Name
Preferred Name/Nickname
Leave Blank if same as above
Gender*

FemaleMale
Age*
Age at time of camp (12-15 years old)
Emotional Age*
Birth Date*

MonthDayYear
Referred by:

Case WorkerTeacherLaw Enforcement OfficerOther
Name of Teen's Case Worker (if applicable)

First NameLast Name
Case Worker's Phone Number

Area CodePhone Number
Case Worker's Email
example@example.com
Name of Person Teen Lives With*

First NameLast Name
Relationship to Teen*
Bio-Parent,Adoptive parent,Foster parent,Relative,etc.
Name of second adult/parent

First NameLast Name
Relationship to Teen
Bio-Parent,Adoptive parent,Foster parent,Relative,etc.
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Second Email/Work Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Length of Time teen has been in this Home*
How many times has the teen been moved in foster placement?
Has teen attended Camp Hope?*

YesNo
Names & ages of other Foster Children living in this home:
Only if Applicable
Emergency Information
Emergency Contact's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number

SECTION 3: Medical History
Doctor's Name*
Facility Name*
Phone Number*

Area CodePhone Number
Health Insurance/ Medicaid*
Insurance Number*
Name of Counselor/Pshchologist
Counselor Phone Number

Area CodePhone Number
Date of last tetanus booster (TDAP)?*

Please answer Yes or No.*

	YES	NO
Allergic to Bee Stings?
Carries an Epi-Pen?
Seasonal Allergies?
Diabetic?
Asthma?

Please Check ANY known health related issues below

AllergiesMental Health Medical ConditionFood AllergiesPhysical Medical ConditionSurgeries treated by a doctorDisabilitiesDevelopmental DelaysOther
If you checked any of the boxes related to health issues above, please explain further in this box below.
Please list ALL medications teen is taking AND what it is for. Medications MUST be in original prescription bottles from prescribing physician. THIS IS NOT THE TIME TO GIVE MEDICINE VACATIONS. *
Name, Taken for, Dosage/Amount, Time Given

SECTION 4: Emotional & Behavioral History

Indicate the degree to which the teen displays the following emotions/behaviors. Please answer honestly. Negative behaviors DO NOT disqualify a teen from attending camp.*

	Daily	Weekly	Monthly	Almost Never	Never
Aggression/Anger
Bedwetting
Biting
Eating Disorder
Hyperactive
Lying
Nightmares
Runs Away
Sexual Acting Out
Stealing
Withdrawn/Sad
Self Harm

Please explain any behaviors from above chart and describe how they are handled.*
What are coping skills that your teen utilizes to assist them in calming down?
We strive to create a supportive and understanding environment for all our teens. To ensure that all campers feel comfortable and safe, please share any family circumstances that may impact their well-being or that you believe our staff should be aware of. This information will be kept confidential and used to ensure each camper has the best possible experience.
Any further information you would like us to know about your teen, please explain below.

Camp Hope Program Sign Up
Caregivers/Parents can choose which months they want their child to join in on Camp Hope activities. This will help us plan events and ensure a smooth and enjoyable experience for all participants.

Mt. Pleasant Police Department Jr. Police Academy - March 8, 2025 - 8:15AM - 12:30pm (lunch will be provided) 8811 Campus Dr. Mt. Pleasant Police Department.Mt. Pleasant Police Department Jr. Police Academy - April 12, 2025 - 8:15AM - 12:30pm (lunch will be provided) 8811 Campus Dr. Mt. Pleasant Police Department.May 2025 - TBD (we will send out email as soon as we determine what this event will be.)Camp Hope Cooking- July 19th - 1pm to 5pmCamp Hope -Kick Off - August 16th - 1:00pm to 5pmCamp Hope - September 6th - Career Readiness -1:00pm to 5pmCamp Hope - October 18th - Career Readiness - 1:00pm to 5pmCamp Hope - November 15th - Career Day Fair and Friendsgiving Party - 1:00pm to 6pmOperation Christmas Cheer - December - Date to be determined.
LIABILITY RELEASE: Every precaution will be taken to protect campers and volunteers from harm, but Camp Hope/Hope City Church/Faith Hope & Love, is not liable for injuries/death that youth or volunteer staff may incur while participating in Building Hope activities. If he/she is injured, I have given medical information and permission to take him/her to a medical facility for proper care. All extension activities are included in the liability release. I release Camp Hope/Hope City Church/Faith Hope & Love from any liability surrounding any injuries/death to the camper and/or the camper's unborn child if the camper is pregnant.
Enter a photo of your teen. Please be sure it is one they like! It will be used as their photo id.
Confirmation

As legal guardian of the above youth, I agree that all the information provided in this application is accurate. I also agree to both the medical and liability releases and the permission to administer first aid and over-the-counter medications as incdicated in Section 5 above.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature of Legal Guardian (Parent/Foster/Adoptive/Relative, etc)*
Printed Name:*
First and Last
Signature of Case Worker (If necessary/applicable)
Printed Name:
First/Last Title
Should be Empty:

Camp Hope Day Camp Registration

Camp Hope