Apply for Camp Diva Leadership Academy

Rising 7th & 8th Application

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Camp Diva Leadership Academy – Rising 7th & 8th Grade

Camp Diva Leadership Academy Application - Rising 7th + 8th Grade

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Step 1 of 6 - Participant

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Participant Information

In this section, we'll need information for the Participant who wishes to apply to the Camp Diva Leadership Academy.

Participant Name*

First Last

Participant's Date of Birth*

Current School*

Rising Grade*

Please ensure that you are completing the correct application for the grade that you will be entering in the fall.

T-Shirt Size*

Please list all additional programs that the participant will be concurrently attending.*

Enter "NONE" if the participant will not be attending any other programs.

Primary Parent or Guardian

Primary P/G Relationship*

Title (Optional)

Your Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alt. Phone (Optional)

Email Address*

Place of Employment*

Enter "N/A" if not applicable.

Work Phone Number

Secondary Parent or Guardian

Relationship to Participant*

Title (Optional)

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alt. Phone (Optional)

Email Address*

Authorized Pickup Permission

Please list up to two additional people who have authorization to pick up the Participant. Please remember that these persons must provide a driver's license when picking up the child.

Person 1 Name

Person 1 Relationship to Participant

Person 1 Phone

Person 2 Name

Person 2 Relationship to Participant

Person 2 Phone

Unauthorized Pickup Person(s) (Optional)

Please list up to two additional people who DO NOT have authorization to pick up the Participant. In compliance with VDSS, you must provide us with documentation that this person is unauthorized to have contact with the child.

Unauthorized Person 1 Name

Reason

Unauthorized Person 2 Name

Reason

I acknowledge that if the Participant's parent or guardian does NOT have permission to pick up the child from the center, a copy of all supporting court documentation must be submitted to Girls For A Change by the Participant's first day of attendance.

I agree

Emergency Contacts

Please list the two contacts we should attempt to reach in the event of an emergency. THESE CANNOT BE A PARENT/GUARDIAN OR SOMEONE PREVIOUSLY MENTIONED ABOVE.

Person 1 Relationship to Participant*

Person 1 Name*

Employer*

Write N/A if not applicable

Phone*

Alt. Phone (Optional)

Business Phone (Optional)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Person 2 Relationship to Participant*

Person 2 Name*

Employer*

Write N/A if not applicable

Phone*

Alt. Phone (Optional)

Business Phone (Optional)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Info to know in the event of an emergency (Optional)

Notification of Reportable Communicable Diseases and Life Threatening Diseases*

I agree to inform the center within 24 hours or the next business day in the event the Participant or any member the household in which the Participant resides has developed/contracted and reportable communicable disease as defined by the Virginia Department of Health. I also understand that life threatening diseases must be reported immediately.

I understand and agree to the above statement.

Medical Treatment/First Aid Authorization*

I grant permission for the administration of First Aid to my child by the staff of Girls For A Change (GFAC), and those transporting my child to and from programs as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when a delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/ guardian of the participant and emergency contact. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child.

I understand the above statement and consent

Release GFAC From Liability*

I, the undersigned parent or legal guardian, release Girls For A Change, or any other person acting on their behalf, from liability for any bodily injury sustained and loss or damage of any personal article while on the premises or participating in any activity sponsored by Girls For A Change. I also permit Girls For A Change to seek medical treatment as deemed appropriate through EMS/911 and/or local hospitals.

I understand the above statement and release GFAC from liability

Publicity Media Consent*

Unless a letter to the contrary is received by Girls For A Change, I give permission to use this Participant’s picture on the official Girls For A Change website, social media, in newspaper advertisements, or other publications.

I understand the above statement and consent

Field Trip Transportation Consent*

I hereby give permission for my child to be picked up and transported to the field trip location and returned to the camp location for field trips and other Girls For A Change programs and activities. You will be provided with a list of field trips and dates at least two weeks in advance. (All field trips are subject to change.)

I understand the above statement and consent

Participant Medication Information

Allergies to Medications*

Please type N/A in the boxes below if your child is not currently taking or allergic to any medications.

Medications Currently Taken*

Please list all the medications the Participant is currently taking. Type N/A in the box below if no medications are currently taken by the Participant.

Health Insurance Information

Policy Holder Name

Insurance Company

Policy #

Authorized Physician Name

Physician's Phone

Apply for Camp Diva Leadership Academy

Rising 7th & 8th Application

Camp Diva Leadership Academy – Rising 7th & 8th Grade

Camp Diva Leadership Academy Application - Rising 7th + 8th Grade

Participant Information

Primary Parent or Guardian

Secondary Parent or Guardian

Authorized Pickup Permission

Unauthorized Pickup Person(s) (Optional)

Emergency Contacts

Additional Information

This Information is to be Completed by the Participant

Participant Medication Information

Health Insurance Information

Code of Behavior

Camp Rules and Regulations

Pick Up by an Intoxicated Parent/Guardian or Authorized Representative

Non-Custodial Parent Policy

Grievance Policy for Parents/Guardians

Consequences

Payment/Refund Policy

Payment Policy

Refunds

Steps

What to Bring to Camp:

Additional Information

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