Camp Life II Camper Application : Camp LIFE : Independent Living : Programs : What We Do : Children's Aid Society

July 19-21 we will be hosting a camp for IL youth between the ages of 14-16 years old. Activities of the camp will build self-confidence, team work, positive peer and adult connections and independent living skills among youth. Youth will participate in closely supervised activities within their small group such as team building activities, talent, basketball, dance and other positive social interactive activities. All camp activities will provide opportunities for campers to develop relationships with their peers and other group members in order to trust and understand each other. Camp Life I will be held on the grounds of the University of Montevallo. Youth will experience a fun and safe environment on a college campus! (***YOU MAY REGISTER 1 CAMPER PER FORM, enter n/a or an x for any unused fields***)

Youth Information

First Name (Required)

Last Name (Required)

Age (Required)

Date of Birth (Required)

Gender (Required)

Race (Required)

Group Home/Foster Parent/House Parent Name (Required)

Group Home/Foster Parent/House Parent Phone Number (Required)

Group Home/Foster Parent/House Parent Email (Required)

County Youth Currently Resides (Required)

Youth T-Shirt Size (Required)

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Any information that may help us better serve this particular youth? (Required)

Does youth have any medical and/or psychiatric history? If yes, please fill out information below, details are required for camp nurse

Youth Medical Diagnosis and Mental Health Diagnosis (if it does not apply please type N/A) (Required)

Current medications (please make note of any recent or pending changes and include dosage and times for administration) (Required)

Allergies and/or Special Dietary Restrictions? (Required)

Transportation (PLEASE NOTE: Youth are NOT permitted to drive themselves to camp unless we receive written approval from their guardian!!!)

Madison County DHR (North Bus)
Jefferson County DHR (North Bus)
Montgomery County DHR (South Bus)
Mobile County DHR (South Bus)
Car

Please note: If youth at anytime engages in behavior that is deemed a safety risk, CAS and SDHR will contact social worker utilizing information provided below. If youth needs to be removed from camp, social worker and county are responsible for ensuring this occurs as soon as possible.

DHR Worker Information

Name (Required)

County (Required)

Phone Number (Required)

Alternate Phone Number (Required)

Email Address (Required)

County After Hours Contact and Phone (Required)

Camp LIFE

Youth Information

DHR Worker Information

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