Camp FRESH Application 2023

Youth's Name (First and Last):

Student ID or Lunch ID:

Current Grade:

Name of Current School:

Please specify:

Are you a member of your school's Wellness Center (School Based Health Center)?

Name of School Attending in Fall 2023:

Please specify:

Have you attended Camp FRESH before?

Year (please select the most recent year)

Were you referred to Camp FRESH through a community center (e.g., William Hicks Anderson, Rose Hill, PALW)?

Please specify:

Please specify:

Please select youth's shirt size:

Which of the following best describes your race?
Please select all that apply.

Please specify:

What is your ethnicity?

What language do you primarily speak at home?

Please specify:

What is your current gender identity?
Select all that apply.

Self-identify as:

What are your pronouns?
Select all that apply.

Please specify additional pronouns:

Home Address:

City:

Please list city:

State:

Zip Code:

Youth's Phone Number:

Youth's Email:

Parent/Guardian Name (First and Last):

Parent/Guardian's Phone Number:

Do you and your youth share the same home address?

Home Address - please include city, state & zipcode (if different from youth):

Parent/Guardian's Email:

Please select the option that applies to your youth.

Please upload a copy of your youth's Medicaid Card.

Definition of Medicaid Eligibility: Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI).

Based upon this definition, is your family eligible for Medicaid?

Please select the option that best applies to your youth.

Does your youth have a Primary Care Physician (PCP) or Pediatrician?

Has your youth had a physical completed within the last year?

Please upload a copy of your youth's physical:

Does your youth have any allergies (food e.g., peanuts, medication, latex)?

Please select all that apply.

Please specify allergen(s):

Does your youth have any dietary restrictions/needs (vegan, vegetarian, no pork, etc.)?

Please specify restriction(s):

Below are some common concerns of youth and families. Please select any concerns you or youth may have that you would like us to discuss as a topic with your youth during Camp FRESH:
Please select all that apply.

Please specify other concerns:

Please specify if the issue(s) you selected is/are an issue specific to your youth or another family member.

Camp FRESH Contract:

Camp FRESH youth will be paid $250.00 at the completion of the program. Payment will be paid via a ClinCard.

Camp FRESH youth will not utilize cell phones for any purpose aside from emergency phone calls or to arrange transportation. Youth may only charge their phones during approved times. Cell phones may be placed in a bag and kept in the coordinator's office. Cell phone use for any other reason will be grounds for being asked to leave that day's session.

Camp FRESH youth are not to bring in food or drinks to the building; if youth are caught with food or drinks, they will be asked to turn them over to staff. Camp FRESH provides two meals - lunch and dinner, along with a healthy snack and water.

Camp FRESH youth will not engage in acts of physical violence or bullying, use offensive language, or disrespect staff or other participants. This behavior will not be tolerated and will be grounds for being asked to leave the program.

Camp FRESH youth who are caught stealing from staff or other youth, caught with alcohol or drugs, caught with weapons (including toy weapons or any object that can be used as a weapon) will be dismissed from the program and will not be eligible for any incentives.

Camp FRESH youth who are asked to leave 2 times for any issue mentioned above will be dismissed from the program.

Camp FRESH staff reserve the right to send any youth home if their behavior is causing disruptions, in addition to anything listed on this contract.

ChristianaCare is not responsible for providing transportation to and from this program. ChristianaCare will provide Camp FRESH youth with DART bus passes to cover the costs for public transportation at no expense to the youth. In addition, ChristianaCare staff will ensure youth are taken safely to the DART stop outside the facility. Camp FRESH youth are to adhere to all DART policies while traveling on public transportation.

Camp FRESH youth's hours count toward community service; however, if a youth is asked to leave the program, staff reserve the right to not authorize the hours worked.

I agree for my youth to participate in Camp FRESH 360 as a commitment to my contract with Camp FRESH.

Camp FRESH Dress Code

During their summer at Camp FRESH, we want your youth to have the best experience possible. This dress code ensures your youth's safety and comfort for a positive Camp FRESH experience. It will be enforced for all youth attending Camp FRESH, at all times.

Camp FRESH youth:

1. Will wear a Camp FRESH t-shirt at all times, unless directed otherwise (t-shirts will be distributed to youth on their first day of camp June 20th or June 21st, depending on your youth's schedule)
2. Will wear closed-toe shoes only (no flip flops or sandals); athletic/tennis shoes are recommended
3. Will wear appropriate swimwear for all water recreation
a. Swimming trunks for males: No shorts, cut-off pants, or Speedos
b. Swimsuits females: One-piece suits recommended
4. Will not wear articles of clothing which display profanity, products, or slogans which promote tobacco, alcohol, drugs, sex or are in any other way distracting or offensive
5. Will not wear excessively baggy or tight clothing
6. Will not wear items of clothing which expose stomach, chest, undergarments, or are transparent (see-through)
7. Will not wear clothing which are inappropriately short shorts or skirts

If your youth chooses to dress inappropriately, they will be asked to change or will be sent home for the day.

Camp FRESH Attendance Policy

The Camp FRESH program will run from June 20th to August 10th, two days each week, for all age groups. The hours are 11am-5:00pm for all youth. Parents will have until 5:30pm to pick up youth from our facility. Camp FRESH staff recognizes that some youth are sometimes involved in additional programs and opportunities. The goal of this policy is to accommodate youth with the flexibility to attend outside opportunities for self-betterment, while at the same time fostering the youth's commitment and dedication to Camp FRESH.

If you know in advance that your Camp FRESH youth will be missing sessions of the program, please share these dates with staff as soon as possible. This will be helpful with planning.

1. Camp FRESH youth can only miss up to 4 sessions without penalty.
2. Youth missing 5 or more sessions will not be eligible for the $250 stipend.
3. Select accommodations will be made for medical or family emergencies. However, if possible, notice should be given to the staff prior to any absences from Camp FRESH.
4. Camp FRESH youth may only be late one (1) time. Late is defined as anything beyond 11:15 AM. THIS POLICY WILL BE STRICTLY ENFORCED. Any additional instances where a participant is late will be considered an absence.

Please sign to indicate that you have read and understand the information above and will be responsible for your youth's actions as a participant of Camp FRESH. Failure to follow any of the rules set forth in this agreement may serve as grounds for being ineligible to receive the $250 stipend at the end of the program.

Camp FRESH
Release of Liability and Statement of Responsibility
(Must be completed and electronically signed by the parent or legal guardian)

This Agreement concerns the risks associated with your youth's participation in Camp FRESH. It has important legal consequences. The final decision to send your youth to Camp FRESH should only be made after you read and fully understand the terms of the Agreement and agree to be bound and have your youth be bound by its terms. For convenience and clarity, the term "I" refers to you, the signer (parent or guardian). "My child" refers to your youth, and Christiana Care Health Services is hereafter referred to as "Christiana Care".

1. I certify that I am the parent or legally appointed guardian of the child named above.

2. I understand that reasonable care and precaution will be taken to avoid accidents, that medical personnel will be available at Camp FRESH, and that all children participating in Camp FRESH will be under close supervision. I understand that the program may pose risks of illness or injury because it involves vigorous activity, gatherings of groups of people, and outdoor settings. In return for ChristianaCare accepting my child into Camp FRESH, I release ChristianaCare and its employees and volunteers from all liability which may result from my child attending Camp FRESH, using the facilities, and/or participating in Camp FRESH events, including any injury to my child or damage to my child's property, or any injury to another person caused by child.

3. I understand that if my child becomes ill or is injured while at Camp FRESH, the staff will contact me and I will be responsible for picking up my child.

4. I understand that ChristianaCare is not responsible for providing transportation to and from this program. However, ChristianaCare will provide Camp FRESH teens with DART bus passes to cover the costs for public transportation at no expense to the participant. In addition, ChristianaCare staff will ensure participants are taken safely to the DART stop outside the facility. Camp FRESH participants are to adhere to all DART policies while traveling on public transportation.

Do you give permission to ChristianaCare and its employees and volunteers to use photographs taken of your youth while attending Camp FRESH, for the purpose of promoting the program and/or any other programs sponsored by ChristianaCare, including use of photos on ChristianaCare's website?

Yes, I hereby give permission to ChristianaCare and its employees and volunteers to use photographs taken of my youth while attending Camp FRESH, for the purpose of promoting the program and/or any other programs sponsored by ChristianaCare. I understand that I may revoke this decision at any time.

No, I do not give permission to ChristianaCare and its employees and volunteers to use photographs taken of my youth while attending Camp FRESH, for the purpose of promoting the program and/or any other programs sponsored by ChristianaCare. I understand that I may revoke this decision at any time.

Camp FRESH staff includes our Community Health Workers (CHWs).

Community Health Workers are certified to help your youth navigate the healthcare system and also to work through their personal goals during their time at Camp FRESH.

What a Community Health Worker can do for your youth if you (parent/guardian) agree:

• Be a support person who will help your youth reach their own health goals during the Camp FRESH Summer Enrichment Program. Your Community Health Worker will meet with your youth at least once a week to check in during their time at Camp FRESH.

• Meet your youth at social service offices, fitness centers, or any other out-of-school/out-of-Camp FRESH location that meets their desired health and/or life goals.

• Stop by your home to check on your youth or to work on their desired goals.

• Make sure your youth has a primary care doctor and has an appointment scheduled if necessary.

• Connect your youth to resources like transportation, insurance, food assistance, utility assistance (e.g. water, electric services, etc.), drug and alcohol counseling and more.

*Text or call your youth's personal phone before or after Camp FRESH hours to check in on objectives. Call and messaging rates may apply.

What a Community Health Worker cannot do:
• Pay for any of your medicines or services.
• Give you any medical advice or care.
• Give you rides in their personal car.

Your Community Health Worker will discuss your youth's care with their manager who supervises their work. Your youth's Community Health Worker will also discuss their care with the Camp FRESH team so that we can coordinate their care as much as possible. Your youth's Community Health Worker will protect your youth's privacy and keep your youth's information confidential. Participation in this program is voluntary. If you choose for your youth to not participate or for your youth to stop working with their Community Health Worker, it will not affect their medical care or insurance coverage in any way, nor will it affect their ability to participate in the Camp FRESH program.

By participating in this program, you agree for your youth to work with a Community Health Worker:

Please add signature to confirm you are in Agreement with your youth being assigned a Community Health Worker. Please note, you have the right to revoke this decision at any time.

Do we have your permission to contact your youth by email and *phone, including text messages?

*Call and messaging rates may apply.

First and Last Name

Phone Number