Theme: The Summer That Cranked
Camp Dates: June 22- August 15, 2026
Camp Hours: Monday to Friday, 8:10 AM - 4:00 PM
Before Care: 6:30 AM-8:00 AM *ADDT'L FEE
After Care: 4:00 PM -6:00 PM *ADDT'L FEE
Ages: 6 to 17
Location: Temple Hills, MD
REGSITRATION FEE: $25 (Non-Refundable)
CashApp: $MAPACPerforms
Confidentiality Notice: All information collected on this form is confidential and protected under HIPAA and Maryland state confidentiality laws. Information will only be used to provide services and support the safety and well-being of your child.
Camper Full Name:
Preferred Name/Nickname:
Age as of June 23, 2025:
Gender Identity:
TShirt Size (Please indicate Youth or Adult)
SECTION 2: PARENT/GUARDIAN INFORMATION
Parent/Guardian Full Name:
Relationship to Camper:
Primary Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Zip:
SECTION 3: EMERGENCY CONTACT AND HEALTH DISCLOSURE
Name:
Relationship to Camper:
Phone Number:
Format: (000) 000-0000.
Alternate Phone if available:
Format: (000) 000-0000.
I authorize MAPAC and _________________________ (Therapeutic Wellness Center) to seek emergency medical care and, if needed, exchange relevant medical information with emergency personnel or medical providers for treatment purposes.
SECTION 4: HEALTH, INSURANCE & SAFETY INFORMATION
Note: If your child is enrolled in Medicaid, _________________________ (Therapeutic Wellness Center) may be able to bill for applicable behavioral health support services delivered during camp hours. Parents will be contacted before any billing occurs.
Social Security Number last 4 digits:
Medicaid Insurance Provider (if applicable):
Medicaid Insurance Number:
Does your child have any medical conditions?
Yes
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No
If yes, please explain.
Does your child have any allergies?
Yes
No
If yes, please list.
Does your child take any medications?
Yes
No
If yes, please list and explain.
Can your child participate in full physical activity?
Yes
No
If no, please explain.
Does your child currently receive behavioral health services (e.g., therapy, counseling, medication management)?
Yes
No
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If yes, please explain and provide current provider contact if available.
SECTION 5: PROGRAM DETAILS
Type a question
Week 1 (June 15-June 19)
Week 2 (June 22 -June 26)
Week 3 (June 29-July 2)
Week 4 (July 6-July 10)
Week 5 (July 13-July 17)
Week 6 (July 20- July 24)
Week 7 (July 27- July 31)
Week 8 (August 3-August 7)
Week 9 (August 10- August 15)
Is your child enrolled in MARYLAND Medicaid?
Yes
No
Would you be interested in before/after care services if they became available?
Yes
No
SECTION 6: RELEASES AND SIGNATURES
PHOTO & VIDEO RELEASE: I give permission for MAPAC and _________________________ to photograph or video my child during camp activities. Yes
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No
Emergency Medical Release: I authorize MAPAC and staff to seek emergency medical care for my child if I cannot be reached.
Yes
No
Behavioral Health Services Consent: I authorize to provide behavioral health support or emotional regulation interventions for my child as needed during camp programming.
Yes
No
As part of our camp program, each child is required to have an adult participate in behavioral health services alongside them. This support helps campers get the most out of their experience, reduces missed days, and strengthens family relationships.
Our behavioral health team provides group sessions aligned with camp activities, as well as one-on-one support for both children and their participating adults. They are available on-site and, in the field, to respond to needs in real time, assist with community resources, and offer additional support through home visits and outings.
We are proud to have a dedicated team of providers you will come to know and trust. For families who continue services during the school year, support can extend to afterschool activities and events.
Please feel free to speak with any of our camp counselors about their experiences with these services, or connect with our behavioral health staff, who are always available to answer questions.
Participation Agreement: I understand and agree to follow all camp rules and policies. I will provide breakfast and lunch daily and ensure timely drop-off and pickup.
Liability Release: I understand that participation in physical activities and arts programming includes a risk of injury. I release and hold harmless MAPAC, their staff, volunteers, and affiliates from any and
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all liability or claims for injuries, loss, or damage arising from my child's participation in the program.
I understand that ________________________________________________ and MAPAC are not responsible for personal items lost or damaged during camp. I also acknowledge that behavioral incidents may require temporary removal from programming for safety reasons.
ParentGuardian Signature
Date Received MM/DD/YYYY
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Year
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Registration Fee per child *NON-REFUNDABLE*
$
25.00
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Payment Methods
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After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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