2022 Summer Collabs Registration

Participant Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Age*
Email
Cell Phone*
School
Current Grade
Expected year of high school graduation:
Race/Ethnicity
- American Indian or Alaska Native
- Asian
- Black or African-American
- Native Hawaiian or Other Pacific Islander
- White
- Prefer Not to Answer
- Other
Shirt Size*
Would you like to receive AMEND Together text message reminders for meetings/events?*
Parent/Guardian Information
Name*
First Last
Relationship to camper*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Cell Phone*
Work Phone*
Annual Household Income
Other:

Camper Health Form
In case of emergency contact name:*
First Last
Phone*
Relationship to camper*
Name*
First Last
Phone*
Relationship to camper*
Physician
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Dentist
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Preferred Hospital
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Insurance Provider (if applicable)
Medical Record*
Current Medication Name Dosage Time

If the camper has no medications, please type N/A in required boxes.
Check all that apply:
- Allergies (food/medicine/other - please describe below)
- Visual Impairment (glasses or contact lenses included)
- Hearing Impairment
- Serious Medical Condition (please describe below)
- Other (please describe below)
Allergies Explanation:
Serious Medical Condition Explanation:
Other Explanation:
Medical/Surgical Authorization*
The undersigned parent/guardian understands that emergency contacts are expected to readily respond in the event of an emergency. In the event of an emergency in which the emergency contact(s) cannot be reached, the undersigned parent/legal guardian hereby appoints the AMEND Together of YWCA Dayton staff the power to consent on our behalf to any and all emergency decisions of my child/ward determined to be necessary or desirable to my camper. Any nurse, physician, or hospital may assume and rely that this authorization is currently in effect during such period unless notified in writing to the contrary. The undersigned parent/legal guardian certifies that they have read this authorization (or have had read to them) and that they understand.

Financial Assistance Form
Complete ONLY if seeking financial assistance; financial assistance amounts vary depending on program funding and need.
Why are you applying for financial assistance?
Would your camper be able to participate without financial assistance?
Camp costs $35 per camper, per session, or $150 per camper for all 5 sessions. How much can your family pay?
Number of people in household:
Annual household income (estimated):
Please attach ONE of the following to verify income: Copy of prior year tax return OR past three (3) months of pay stubs. Allowed file formats: jpg, png, pdf, doc, docx.
Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 4.
Financial Agreement
I understand that if my camper receives financial assistance from AMEND Together of YWCA Dayton and does not attend the collabs, I am responsible for paying the full program fee.

Authorizations
The following individuals have authorization to pick up my camper. Note: Individuals MUST be 18 years or older and will need to check in with staff to authorize release of camper.
Name*
First Last
Phone*
Relationship to camper*
Name
First Last
Phone
Relationship to camper
Name
First Last
Phone
Relationship to camper
Consent*
I certify that the above information is true and correct to the best of my knowledge. I understand the necessary commitment to the AMEND Together mission and the program requirements. I understand that the AMEND Together of YWCA Dayton program is not obligated to place me with their organization, nor am I obligated to accept this program opportunity.
Waiver & Release*
As a condition of my child/ward's participation in the AMEND Together program, I understand and hereby assume all inherent risks involved in the AMEND Together program in which my camper will participate. I expressly assume the risk of and accept full responsibility for any and all injuries and accidents which may occur as a result of or in connection with my camper's participation in the AMEND Together program. I release from liability against any and all claims or causes of action by AMEND Together of YWCA Dayton. I hereby waive and relinquish any and all such claims or causes of action I may hereafter have for any and all injuries to my camper's person or property (including but not limited to loss of personal property) as a result of my camper's participation in the AMEND Together program.
Transportation Release*
I hereby further authorize and consent to my camper's transportation in any vehicle (whether public or private) in connection with my camper's participation in any AMEND Together program, activities, and/or field trips.
Media Release
I hereby authorize and consent to the use of any photographs, videos, recordings, or other records in which my camper appears. I understand that my camper's name will not be given and the photographs/videos will be used in public domains (website, publications) and may be submitted to funding organizations. I waive any right to inspect and/or approve the finished product or advertising copy that may be used or the use to which it may be applied. I hereby release, discharge, and agree to waive AMEND Together of YWCA Dayton from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in the taking of said picture/video; or in any processing tending toward the completion of the finished product.
Confirmation*
I certify that I have read and fully understand these waivers and releases; that I execute the same voluntarily and of my own free will; and that I am of lawful age and legally competent to do so.
Electronic Signature*

2022 Summer Collabs Registration

Collabs will be held in-person, June 27-July 1, 2022.
We continue to monitor and follow all CDC pandemic guidelines to ensure safety and wellness for all.

$25 application fee required to process application.
SPACES ARE NOT RESERVED until application fee is submitted.

AMEND Together Summer Collabs 2022

Step 1 of 5 - Camp Information

Participant Information

Parent/Guardian Information

Camper Health Form

Financial Assistance Form

Authorizations

24/7 Crisis & Domestic Violence Hotline: 937-222-SAFE (7233)

Current Medication Name	Dosage	Time

2022 Summer Collabs Registration

Collabs will be held in-person, June 27-July 1, 2022. We continue to monitor and follow all CDC pandemic guidelines to ensure safety and wellness for all.

$25 application fee required to process application. SPACES ARE NOT RESERVED until application fee is submitted.

AMEND Together Summer Collabs 2022

Step 1 of 5 - Camp Information

Participant Information

Parent/Guardian Information

Camper Health Form

Financial Assistance Form

Authorizations

24/7 Crisis & Domestic Violence Hotline: 937-222-SAFE (7233)

Collabs will be held in-person, June 27-July 1, 2022.
We continue to monitor and follow all CDC pandemic guidelines to ensure safety and wellness for all.

$25 application fee required to process application.
SPACES ARE NOT RESERVED until application fee is submitted.