2023 Footprints Summer Therapy Camp Application

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* 1. Child's Name and Date of Birth:

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* 2. Parents names and address:

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* 3. Phone and email:

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* 4. In person or virtual camp?

In person - child comes to camp every Monday from July 10 - July 31 from 8:30-11:30. I understand I should make every effort for my child to be there every week since camper slots are limited.

Virtual - pick up camp bag on Monday July 10 at 11:30 at North Hills and will receive link to recorded zoom session each week with therapists' description of activities. I understand I should watch the recorded Zoom session each week and complete the activities with my child.

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* 5. In case of emergency, what number should we call?

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* 6. Does your child have access to therapy services in the summer?

Yes

Yes, but limited

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* 7. What are your child's special needs?

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* 8. If your child has any allergies (food, seasonal, environmental, etc), please list here:

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* 9. How much assistance does your child need with feeding/eating and toileting? Any other information we need to know about your child?

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* 10. Please type your name in the box below to indicate your understanding of the following:
I understand that all information about my child that I provide to Footprints in the Community will only be shared with camp personnel for the purpose of serving my child in the camp. I understand that data collected during the camp will be used for the purpose of documenting and reporting improvement and in development of the camp. Data will be used in reports provided to individuals outside the camp for the purpose of promotion and fundraising; however, children will not be identified in relation to their individual progress. I understand that photographs and video of my child taken during the camp will be used for promotion of the camp and for Footprints in the Community, which may include, but is not limited to, promotional materials, advertising, fundraising materials, and Footprints website.

I understand that in the case of an emergency, Footprints staff will contact my emergency contacts listed and will call for medical help as is necessary. I absolve Footprints staff and North Hills Christian School in the event of an emergency during the Footprints camp on NHCS campus.

I will receive an email or text from Ashley Deaton confirming my child's spot at camp after 6.1.23 and will receive more information from her at that time.