Housing--W | Femergy

Chica Sports & Fitness Overnight Camp Application

We recommend filling out this application on a desktop computer. Please expect to spend 15-20 minutes completing this application thoroughly. If you need assistance filling out this application, please contact us at info@femergy.org.

By filling out this application, you are registering your interest in your child attending. To confirm your child's registration, you MUST attend a mandatory orientation prior to camp. The date and time of the orientation will be communicated to you via email and text in the coming weeks using the contact information provided in this application.

Guardian First Name

Guardian Email Address

Student's First and Last Name

Guardian Last Name

Guardian Phone Number

Relationship to Student (mother, father, grandmother, aunt, etc):

Student's Address

Guardian's Address (if different than student's)

Student's Date of Birth

Student's School:

Student's Grade (24-25 School Year):

Demographics

Demographic information helps us best quantify where the need is in our community, who we're serving, and what additional resources we can provide to families. This information is confidential.

Student's Race and Ethnicity (select all that apply):

Household Size:

Pre-Camp Information

Student's T-Shirt Size

Has your student been to an overnight camp before?

Yes

Does your child have any limitations that would affect full participation in our program?

Share additional information with us to help your child have a successful time while attending our summer program.

Emergency Contact Information

Emergency Contact First & Last Name:

Emergency Contact's Phone Number:

Emergency Contact Relationship to the Student:

Medical Information and Consent

Providing this information helps ensure every participant is safe and healthy while away from home. This information is confidential.

Policy Holder

Policy Number:

Insurance Company:

Group Number:

Does your student suffer from any medical, physical, emotional or behavioral conditions which might affect her safety while at camp? (i.e. claustrophobia, vertigo, asthma, heart condition, diabetes, epilepsy, etc.):

Yes

If yes, please provide additional details:

Does your student have any food, medication, or environmental allergies?

Is your student currently undergoing any form of medical or psychological treatment, including medication?

Yes

Will the student be bringing any prescription or nonprescription medication to camp, including an inhaler or epipen?

Yes

I give permission for staff to give my student the following (select all that apply):

Acetaminophen – Tylenol or Generic

Ibuprofen – Advil or Generic

Cough Suppressant – Robitussin or Generic

Hydrocortisone Ointment

Antacid – TUMS, Mylanta, Maalox, or Generic

Aspirin

Antihistamine – Benadryl or Generic

Decongestant – Sudafed or Generic

Antibiotic Ointment

Release and Declarations

Parental Release

I agree that my above named student may attend the 2024 Chica Sports & Fitness Camp at Salt For Lodge and Conference Center in Cambridge, Ohio.

I give permission for my participant to take part in all of the activities described below.

I acknowledge that these activities involve the risk of serious injury or death. I acknowledge the need for responsible behavior and ability for my child to make sound decisions during camp, and follow all directions/rules.

I understand that I am responsible for my child’s actions and will be held financially responsible for any damage by my child and will pay for any and all repairs incurred by such damage.

The program may include swimming, volleyball, hiking, yoga, tennis, team sports, cardio, field games, and mingling with other individuals etc. Specific activities may be excluded or added – contact the Camp Director at christina.vera@femergy.org with any questions or concerns.

I accept the Parental Release

Please read the following declarations carefully and check yes to agree:

In the event of an accident or an illness during this event that needs immediate treatment, I agree to my child receiving first aid and medical treatment from a including lifesaving treatments, as may be considered necessary by a licensed medical provider

I also authorize the transportation of my child, by ambulance if necessary, to the nearest available medical facility.

I understand the extent and limitation of the insurance coverage as provided by the organization sponsoring the event and that my medical insurance is primary, unless otherwise specified.

I will inform the leaders of the event as soon as possible if there is any change in medical circumstances regarding my child between the date signed below and the start of this event.

(Optional) I give consent for my child to ride in a charter bus or vehicle used for camper transport.

Please read the following Release of Claims and Photo Release carefully:

I hereby agree to indemnify, defend, and hold harmless Femergy®, its Board of Trustees, and its officers, directors, employees, volunteers, agents, affiliates, and all others who could be held liable (collectively, “Femergy®”) from and against any and all claims, causes of action, lawsuits, losses, costs, damages, expenses (including, but not limited to, attorneys' fees) and liabilities due to any injury to or death of any person, or damage to or loss of any property, arising out of or related to Participant’s participation in such activities. I also hereby specifically agree to waive and release any and all claims against Femergy® arising out of or related to any such activities.

I hereby waive, release, discharge, and agree to hold harmless Femergy® from and against any and all liability, loss, damage, and claims of any nature which in any manner arise from or relate to such services or treatment. I understand that the participant’s participation in the above-referenced program and activities is performed under this specific understanding. I have read and understand the foregoing and voluntarily sign this Release of Claims with full knowledge of its contents and significance.

I hereby grant Femergy®, its program personnel and affiliates, permission to use the Participant’s likeness in publications related to the program and mission of the agency, without payment or further consideration. I understand and agree that these materials will become the property of Femergy®. I hereby authorize Femergy®, its program personnel and affiliates, permission to edit, alter, copy, exhibit, print, publish, electronically or otherwise, the photo(s) and or video(s) for their programs, events, bulletins, newsletters, websites, or any other lawful purpose. I have read and understand the foregoing and voluntarily sign this Photo Release.

I accept the Release of Claims

I accept the Photo Release

I understand that by filling out this application, I have completed the first step to enroll for my child for Chica Sports & Fitness Camp. To complete enrollment, I must attend a mandatory orientation (date and time TBD) prior to camp.

I herewith affirm that my electronic signature was signed by myself with full knowledge and consent and am legally bound to the agreements made in this form.

Your Signature

Print Name:

Today's Date:

Thanks for submitting!

We have reached capacity for participation. To be notified if additional spots open up, please register for our waitlist below.