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Agassiz Village Camper Registration
2014 Camper Registration Form
Application Date
*
MM
/
DD
/
YYYY
Session Preference:
*
Session I (July 7 - 18)
Session II (July 21 - August 1)
Session III (August 4 - 15)
* All sessions are Two-Week sessions! You may register for up to TWO sessions. Please refer to our program descriptions at
www.agassizvillage.org for details of each program.
Please Note: INSTEP Program (ages 16-17) is a four-week, tuition-free program for select candidates. It will require a separate application. Please contact us for more details.
CAMPER INFORMATION
Camper Name
*
First
Last
Date Of Birth
*
MM
/
DD
/
YYYY
Age at camp
*
Gender
*
Male
Female
Social Security Number
Camper Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Current Grade
*
School
*
Special or Gifted Class
*
Please select
Yes
No
If yes, please explain below.
Primary Parent / Guardian Information
Parent/Guardian Name
*
First
Last
Relationship to Camper
*
Please select
Mother
Father
Legal Guardian
Foster Parent
Living with camper?
Please select
Yes
No
Email
*
Home Phone
*
###
-
###
-
####
Cell Phone
*
###
-
###
-
####
Work Phone
###
-
###
-
####
Second Parent Name
First
Last
Relationship to camper
i.e. mother, father, grandparent, etc.
Living with camper?
Please select
Yes
No
Home Phone
###
-
###
-
####
Cell Phone
###
-
###
-
####
Work Phone
###
-
###
-
####
Emergency Contacts
Please provide emergency contacts in case the ones above cannot be reached. Emergency contacts must be different from the ones in parent/guardian section.
Emergency Contact 1
*
Name
Relationship to camper
*
i.e. grandparent, aunt, sibling, etc.
Phone
*
###
-
###
-
####
Emergency Contact 2
*
Name
Relationship to camper
*
i.e. grandparent, aunt, sibling, etc.
Phone
*
###
-
###
-
####
Family Information
Number of people in household:
Number of adults:
Number of children:
Ages?
What language is spoken at home?
Language child is most comfortable with?
Ethnic/racial background:
What Organization / Individual (if applicable) referred you to us?
What Organization / Individual (if applicable) will sponsor you?
Organization / Individual Contact Name:
Contact Phone:
###
-
###
-
####
Will you be using transportation to and from camp provided by Agassiz Village?
*
Yes
No
If Yes, you will receive additional information and details in Parent Handbook.
Will you be applying for Agassiz Village FINANCIAL AID?
*
Yes
No
If Yes, complete FINANCIAL AID APPLICATION section below!
Financial Aid Application
To be eligible for financial aid rates you must:
1. Complete this section FULLY.
2. Submit PROOF OF INCOME (i.e. copy of the first page of your Income Tax Return).
After we receive this application we will send you the confirmation with apporved rates based on information provided here!
Total number of people living in your household?
*
Total HOUSEHOLD Income (annually)?
*
How many adults receiving income?
*
Are you receiving federal assistance: Cash Assitance, Food Stamps, TAFDC, TANF, other?
*
Yes
No
Families on Public Assistance (FDPIR, TANF, TAFDC, etc): Please mail a copy of your Benefit Card. We will also mail you an additional form to fill.
Case #
Is this child receiving a Foster Care subsidy?
*
Yes
No
Will you be applying for FULL SCHOLARSHIP?
*
Yes
No
If YES, there will be a ADDITIONAL APPLICATION AND APPROVAL PROCESS. Please call us for more information and forms.
INITIALS:
*
By typing your initials above you confirm that all financial information entered above is correct.
Additional Camper Information
Has your child ever attended Agassiz Village?
*
Yes
No
If yes, when?
Has your child ever been away from home before?
*
Yes
No
If yes, please tell us where?
Does your child have any activity or physical restrictions?
*
Yes
No
If yes, please explain.
Does your child have any dietary restrictions?
*
Yes
No
(e.g. vegetarian, no pork, no peanuts, etc)
If yes, please explain.
Describe your child's appetite:
Does your child have any special fears?
*
(e.g. dogs, dark, heights, other)
What words would you use to describe your child?
(e.g. active, shy, intelligent, etc.)
How does your child handle conflict with other kids?
*
(e.g. hitting, yelling, sulking, crying, running away, etc.)
Does your child have frequent nightmares?
*
Yes
No
Does he/she sleepwalk?
*
Yes
No
Does he/she have history of bedwetting?
*
Yes
No
If yes, how recent and how frequent?
Has your child ever been seen by a therapist / counselor?
*
Yes
No
If yes, when and why?
Has your child ever been prescribed medication by a therapist / counselor?
*
Yes
No
If yes, when and why?
Is your child currently in counseling?
*
Yes
No
If Yes, please provide therapist/counselor name
Therapist/Counselor Phone #
Additional comments about your child:
Terms & Conditions and General Permission Statement:
• I understand that if my child needs to be sent home due to behavioral or other reasons, I take full responsibility for picking him/her up regardless of the location;
• I agree to pay the tuition in full (or ensure that my sponsor will pay in full) at least 2 weeks before start of the session(s) my child is attending;
• I understand that if cancelled less than 2 weeks prior to the start of the session I will forfeit the deposit;
• I understand that if cancelled within 1 week of the start of the session I will forfeit ALL paid fees;
• I allow my child to participate in all activities, including trips pre-arranged by camp;
• I agree to provide a current physical (within last 12 months) and up-to-date immunizations at least 2 weeks prior to the session start;
• I authorize social service agencies, schools, clinics, doctors, etc to release any information necessary to best plan for my child’s stay at camp;
• I give permission for Agassiz Village to take, have and use photographs, slides, videos of the applicant for records, promotion materials or public relations;
• I agree that all information provided in the form is true and hereby release and hold harmless Agassiz Village and its representatives from any claims, causes of
action, demands, judgments, or costs of any nature whatsoever arising out of applicant’s attendance at camp.
By choosing "AGREE" below I indicate that I have read this statement and agree to it's terms and conditions:
*
AGREE
DISAGREE