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North Shore Holiday House
Complete the form to apply for a spot at our summer camp.
Camper's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Returning Camper? Yes or No.
If Yes, in which years did your child attend camp?
Camper lives with...
Mother
Father
Foster Parent
Guardian
Other
Single Parent Household?
Yes
No
Mother's Name:
Father's Name:
Foster Parent/Guardian Name:
Foster Parent/Guardian Relationship:
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Email (This is the email address we will send all camp correspondence to):
*
example@example.com
Parent/Guardian Contact Number (This is the first number we will call when trying to contact you regarding your camper. Please specify whom the contact number belongs to):
Please list all individuals living with the child, including their age and relationship. For example: Lucy Brown, Age 11, Sister
Is either Parent/Guardian authorized to pick up camper?
Yes, both parents/guardians
Mother only
Father only
Other
School/Referring Agency Information
School Name:
Grade Entering in September 2027:
Name of Referring Agency or Social Worker:
Contact Information:
Do you give North Shore Holiday House permission to contact above social worker or referring agency if consultation is necessary?
Yes
No
Emergency Contacts
Please provide the name and contact information of three emergency contacts in the order you would like them to be contacted.
Emergency Contact 1 Name
*
First Name
Last Name
Emergency Contact 1 Relationship to Camper
Emergency Contact 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 Name
First Name
Last Name
Emergency Contact 2 Relationship to Camper:
Emergency Contact 2 Contact Number
Emergency Contact 3 Name
First Name
Last Name
Emergency Contact 3 Relationship to Camper
Emergency Contact 3 Phone Number
Please list the name of the individual who will be picking up your child from camp:
Relationship to Camper:
Contact Number:
By signing below, I certify that all information provided in this application, including contact and emergency contact information, is accurate and complete to the best of my knowledge:
Print Name:
Relationship to Camper:
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Background
Ethnicity:
Hispanic/Latino
Not Hispanic/Latino
Race
American Indian or Alaska Native
Asian
Black or African American
White
Native Hawaiian or Pacific Islander
Mixed
Has the child experienced any of the following events in the past year:
Death of a Relative
Illness
Accident
Hospitalization
Foster Care
Homelessness
Seperation from either parent
Other/Additional Information:
Camp Sessions
Please select the camp sessions you are interested in:
Which
Session 1
Session 2
Session 3
Session 4
Session 5
If you have selected more than one session, please list them below in order or 1st choice, 2nd choice, etc.
My camper is...
Excited
Not Excited
Somewhat Excited
Other:
I give permission for my child to participate in field trips, including transportation for the same:
Yes
No
My camper and I have understood the camp policies, as listed in the parent guide, and my camper is committed to adhering to these policies while at camp:
Yes
No
Signature
Print Name:
Relationship to Camper:
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Should be Empty: