Camp Homelani Camper Application
Is the camper currently involved with a Salvation Army Corps or Kroc Center? If a camper is coming from an outer island please click yes and indicate the Salvation Army location you are working with.
*
Yes
No
Would you like to request a scholarship to attend camp? If you indicate yes for this question, more information will be sent on how to apply for the scholarship.
Yes
No
Which corps do you attend?
*
Hanapepe
Hilo
Honokaa
Kahului
Kaneohe
Kauluwela
Kona
Kroc Center
Lahaina
Lihue
Molokai
Does the camper need transportation to and from camp?
*
Yes
No
Which of our locations do you live close too? For Oahu Campers only.
Oahu Windward
Oahu Downtown
Oahu Kapolei/Ewa
Oahu Waianae
Back
Next
Name of Camper
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
T-Shirt Size
*
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Which Camp would you like to register for?
Each Camp is geared for a specific age group. Campers are only allowed to attend two camps per summer.
Camps
Discovery Camp #1 - Ages 7-12 (June 15 to June 19)
Discovery Camp #2 - Ages 7-12 (June 22 to June 26)
Junior Music Camp - Ages 7-11 (June 29 to July 3)
Senior Music Camp - Ages 12-17 (July 6 to July 13)
Discovery Camp #3 - Ages 7-12 (July 16 to July 20)
Teen Camp - Ages 13-17 (July 23 to July 27)
Back
Next
Parent/Guardian 1
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
Work Phone Number
*
-
Area Code
Phone Number
Back
Next
Parent/Guardian 2
We require two parents or guardians where possible if that is NOT possible please “select NOT possible” in the drop down menu.
*
Continue Adding Parent/Guardian 2
NOT Possible
Parent/Guardian Name
*
First Name
Last Name
Is address same as above?
*
Yes
No
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
*
-
Area Code
Phone Number
Work Phone Number
*
-
Area Code
Phone Number
Back
Next
Emergency Contacts
Two contacts are required. Both must be over 18 years old and different than the parent or guardian, in case the parents cannot be reached.
Emergency Contact 1
*
First Name
Last Name
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
*
-
Area Code
Phone Number
Work Phone Number
*
-
Area Code
Phone Number
Relationship to camper
*
Emergency Contact 2
*
First Name
Last Name
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
*
-
Area Code
Phone Number
Work Phone Number
*
-
Area Code
Phone Number
Relationship to camper
*
Back
Next
Camper Health History
This form is HIPPA Compliant please scroll the the end of this page for a full print out of The Salvation Army’s HIPPA policies and practices.
Does your family have medical insurance?
*
Yes
No
Insurance Provider
Group/Policy#
Name of Child's Physician
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Name of Child's Dentist
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Current and Previous Illnesses and Diseases
Has the camper been exposed to any communicable disease during the months prior to camp attendance?
*
Yes
No
What was the camper exposed to?
Has the camper had COVID-19?
*
Yes
No
What date did the camper last have COVID symptoms?
*
Does the camper have any behavioral problems that we should know about?
*
Yes
No
Please describe:
Please check all that apply
*
None
ADD/ADHD
Asthma
Bed Wetting
Bleeding/Clotting problems
Bronchitis
Convulsions
Diabetes
Dizziness
Eating Disorder
Fainting
Frequent Colds
Frequent Ear Infections
Heart Disease
Homesickness
Hypertension
Kidney Problems
Psychiatric treatment
Sinusitis
Sleepwalking
Stomach upsets
Sunburn
Tuberculosis
Other
Operations or Serious Injuries please include dates:
Allergies and Special Concerns
Please check those allergies the camper has and list details
*
None
Insect Bites/Stings
Penicillin
Poison Ivy
Hay Fever
Other
Other allergies to drugs/medications, please list here
Food allergies or dietary concerns, please list here (Including vegan, vegetarian etc.)
Any other comments or concerns?
For Girls: Has she started menstruating?
*
Yes
No
If no, has she been told about menstruation?
*
Yes
No
If yes, is her menstrual history normal?
*
Yes
No
Camper Physical Exam
It is highly recommended that all campers have a current physical exam on file while attending Camp Homelani. This form should be completed by a licensed healthcare provider within 24 months (2 years) before the first day of camp 2026.
Please select one of the of the options below.
*
My child has seen a doctor in the past 2 years and has a current physical exam
I need assistance with providing a physical exam for my child to attend camp
Upload a copy of your child's current physical exam here.
Browse Files
Cancel
of
Immunizations
All children need to have a current copy of their immunization record for camp files. Campers do not need to have a COVID vaccine to attend camp. Please upload a copy of the campers latest immunization record from their physician. If you have questions regarding the Camp Homelani immunization policy, please call 808-440-1832.
Upload a copy of your child's current immunization record here.
Browse Files
Cancel
of
HIPPA Privacy Practices
Back
Next
Summer Food Program - Income Eligibility
Dear Parents: By filling out this section you help us keep camp fees low. This camp is applying to receive USDA reimbursement for meals served to eligible children. The following confidential information is needed from you for this camp to receive these funds.
Do you receive SNAP, TANF or FDPIR benefits?
*
Yes
No
Enter your SNAP, TANF or FDPIR case number:
*
Is the camper a foster child?
*
Yes
No
Total Household Gross Income
Please complete the following information for anyone in your household who is not currently included in a Food Stamp, TANF or FDPIR case. Under NAME, list EACH PERSON living in your household, including yourself and the camper. List the usual GROSS income (the amount before deductions for taxes, social security, etc.) and how often you receive that income. If the person had more than one source of income, list each amount under the correct column title. PLEASE LIST ALL HOUSEHOLD MEMBERS INCLUDING ALL CHILDREN LIVING IN THE HOUSE.
Please list all CHILDREN and ADULTS living in household, AND list INCOME for ANYONE currently receiving income. Scroll across to each field and put a 0 into each box if there are no earnings for that category.
Do you have a social security number.
*
Yes
No
Last 4 digits of Social Security Number of Parent or Guardian:
*
OPTIONAL: PARTICIPANT’S ETHNIC IDENTITIES
Hispanic or Latino
Not Hispanic or Latino
OPTIONAL: PARTICIPANT’S RACIAL IDENTITIES
Native Hawaiian or Other Pacific Islander
Asian
Black or African American
American Indian or Alaska Native
White
Non-discrimination Statement:
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g. Braille, large print, audiotape, ASL), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202)720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800)877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf from any USDA office, by calling (866)632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by MAIL: US Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue SW, Washington D.C. 20250-9410 FAX: (833)256-1665 or (202)690-7442 EMAIL: program.intake@usda.gov Camp Homelani is an equal opportunity provider.
Privacy Act Statement
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve yourchild for free or reduced price meals. You must include the social security number of the adult household member who signs the application. The social security number is notrequired when you apply on behalf of a foster child or you list a SNAP, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on IndianReservations (FDPIR) case number for your child or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a socialsecurity number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the Program.
Signature:
PENALTIES FOR MISREPRESENTATION: By signing your name, you are certifying that all information in this section is true and that all income is reported. I understand that this information is being given for the receipt of Federal funds. I understand that SFSP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Parent or Guardian Release Signature
*
Name
*
First Name
Last Name
Parent's Release
Please read this Waiver carefully as it affects your legal rights in the event of accident, injury, contraction of a communicable disease, infection and illness. By signing this document you are representing that you have read, understood and agree to be bound by the Terms of this Waiver. In consideration of the permission herein granted, the Grantee shall, to the maximum extent permitted by law, defend, indemnify, and hold harmless The Salvation Army, a California corporation, its officers, directors, employees, agents, and volunteers from and against all claims, actions, suits, liabilities, losses, damages, costs, attorneys’ fees, experts’ fees and/or any other expense of every nature and character, including, without limitation, any injury, loss, contraction of a communicable disease, infection and/or illness and/or contraction of a viral or bacterial infection of any kind and/or damage to property or person, including death, arising from or in connection with the use of the premises by the Grantee, except that the Grantee’s obligations hereunder shall not apply to The Salvation Army’s sole negligence or willful misconduct. Without limiting the foregoing, the Grantee further agrees, to the maximum extent permitted by law, to WAIVE AND RELEASE The Salvation Army, a California corporation, its officers, directors, employees, agents and volunteers from any and all liability, claims, demands, suit, including without any limitation any injury, loss, contraction of a communicable disease, infection and/or illness and/or contraction of a viral or bacterial infection of any kind and/or damage to property or person, including death, arising from or in connection with the use of the premises by the Grantee. Authorization For Medication Distribution: All medication brought to camp, both prescription and over the counter, must be in the original container it was first issued in with any prescribing doctor’s name and dosage information on it and accompanied by written instruction from a physician or the child’s parent/guardian and is to be given to the Health Care Officer upon arrival to Camp Homelani and shall be administered throughout the week by the Health Care Officer. Any and all non-original containers will not be accepted. All remaining medication will be sent home with the camper at the end of the camp session. Authorization For Treatment: I hereby give permission to the medical personnel selected by the camp director to order any x-ray examination, routine tests, treatment and necessary related transportation to said minor. In the event I cannot be reached in an emergency, I hereby give to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the said minor. The completed forms may be photocopied for trips out of camp. Disclaimer – Third Party Insurance: I understand that my child may be participating in activities of The Salvation Army at their own risk, and if injured, The Salvation Army’s Third Party Medical Insurance coverage, if applicable to the injury, will only cover up to $5,000 of the medical expenses. I also understand that The Salvation Army’s Third Party Medical Insurance will not cover any injury resulting from or aggravated by a pre-existing injury or illness. I understand The Salvation Army recommends that all participants in Salvation Army activities carry their own personal medical insurance, which will cover the complete cost of any injury sustained while participating in these activities.
Parent or Guardian Release Signature
*
Name of Parent or Guardian
*
First Name
Last Name
Photo Release
This will confirm the understanding between the undersigned ("I" or “me”) and THE SALVATION ARMY, a California religious corporation ("you") regarding the creation of one or more audiovisual productions (collectively, the "Programs"). Unless otherwise indicated below, I represent to you that I am at least 18 years old. For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby authorize and permit you to use in the Programs and in any advertising, promotion and publicity: my name and voice, biographical information concerning me, and my portrait and likeness, including, without limitation, any statements, interviews or performances by or with me, whether as contained in existing photography or as photographed by you (collectively, "Name and Likeness") and any materials I may furnish in connection with any such interviews or otherwise (e.g., articles, memorabilia, etc.) (collectively, "Content"); and to reproduce, distribute, transmit, adapt, publicly display, publicly perform, and otherwise exploit the Programs and to exploit all allied, subsidiary and ancillary rights therein and thereto, by any and all means and media, whether now known or hereafter developed, throughout the world in perpetuity, provided that nothing shall obligate you to (a) use my Nameand Likeness and/or the Content and/or (b) produce any of the Programs. I release you from any claims that I or anyperson claiming through me may have against you at any time relating to theforegoing uses. You shall have the rightto edit, modify, add to and/or delete any or all of the material contained inthe Programs, including material that contains my Name and Likeness and/or theContent, in whole or in part. Iunderstand that I will receive no further compensation for any of theseuses. I represent that I own allright, title and interest in and to the Content and the exploitation thereofhereunder shall not infringe upon the rights of any person or entity. I hereby release you and your officers,directors, employees, attorneys, agents, representatives, shareholders,successors, licensees and assignees (collectively, “Released Parties”) from anyand all claims, demands, losses, liabilities, actions, causes of action, costsand expenses including, without limitation, attorney’s fees and costs(collectively, “Claims”), arising out of or in connection with use of the Nameand Likeness and Content, including, without limitation, any and all claims forinvasion of privacy, infringement of rights of publicity, defamation (includinglibel and slander) and any other personal and/or property rights. I further release the Released Parties fromany and all Claims arising out of any harm, illness, bodily injury and/or deathresulting from my participation in the Programs. Furthermore, I hereby agree tosave, indemnify and hold the Released Parties from any and all Claims arisingout of any breach by me of any provision of this release. I agree not to disclose to any third party the terms of this release without your consent, except if required bylaw. Furthermore, I agree not todirectly or indirectly circulate, publish or otherwise disseminate any news,story, article, book or other publicity concerning the Programs, you or anythird party related to you or the Programs without your prior written consent. You may assign your rights andobligations contained in this release and agreement to any third party. This release and agreement will be governedby the laws of the State of California applicable to agreements made and to beentirely performed in that state, and may not be modified except in a writingsigned by me and by you. The rightsgranted to you in this release are irrevocable; in no event shall I have theright to seek to enjoin the development, production, distribution,exploitation, advertising or promotion of the Programs or the exercise of anyrights granted to you in this release. I have read this release and I understand it.
Photo Release Signature
*
Name of Parent or Guardian
*
First Name
Last Name
Camper Pledge
If allowed to attend camp, I promise to abide by the camp rules and will cooperate with the staff. I believe that cooperation between campers and staff is needed for good camping. I will not bring or use the following items to/at camp: cigarettes, alcoholic beverages, illegal substances, knives, weapons, and matches. I understand that electronic devices (phones, MP3, games) will be held by camp administration during the camp session and returned at the end of the camp session. I realize that failure to cooperate with the camp rules and policies could lead to my dismissal. I understand the Progressive Discipline plan above will be followed.
Camper Signature
*
Name of Camper
*
First Name
Last Name
How would you like to pay?
*
Credit/Debit Card
Cash
Check
Your spot will be reserved once your payment is made in full. An invoice will be emailed to you within 7-10 business days.
Submit
Should be Empty: