Impact, Empower & Engage Summer Camp Application

Impact, Empower & Engage Summer Camp Application

Please complete the following form. Each applicant must also submit a one-page essay stating his/her reason(s) for wanting to participate in this camp. To select a “check box” option, double-click on the box.

Select Camp According to Grade entering in the fall:

Camp 1 (Grade 6-8th) June 8th-12th, 2015 Camp 2 (Grades 9-12th) July 6th-10th, 2015

Application deadline May 26th, 2015Application deadline June 23rd, 2015

Name (including middle initial*):

Home Address:

Street City State ZIP

Home Phone: Work Phone: Cell Phone:

Age: Grade (2015-16):

Email Address:

Parent/Guardian Information:

Parent/Guardian 1

Name (including middle initial*):

Home Address:

Street City State ZIP

Home Phone: Work Phone: Cell Phone:

Email Address:

Parent/Guardian 2

Name (including middle initial*):

Home Address:

Street City State ZIP

Home Phone: Work Phone: Cell Phone:

Email Address:

……………………………………………………...... ……………………………………………………………………………………………………………………………

Emergency Contacts

Name: Relationship: Cell Phone:

Name: Relationship: Cell Phone:
Does the applicant have any medical conditions camp leaders should be aware of ? Yes No

If yes, please explain:

Does the applicant have any allergies? YesNo

If yes, please explain:

………………………………………………………………………………………………………………………………………………

The following information is not required, but will help FBWC when applying for grant funding.

Gender: Male Female

Ethnicity: Caucasian African-American Hispanic Asian

Native American Other (please specify)

Parental Agreement/Waiver

I, ______, give permission for my child, ______to participate in the Fort Bend Women’s Center Summer Camp. I understand the camp will cover topics concerning teen dating violence, sexual harassment and healthy dating practices. I understand my child will be volunteering each day at the PennyWise Resale Center as part of the camp program. I release Fort Bend Women’s Center and PennyWise Resale Center for all liabilities or responsibilities pertaining to accidents, injuries or complications resulting from activities. I authorize the Fort Bend Women’s Center Summer Camp Trainers and/or staff to transport the above named participant to the nearest hospital, by ambulance or other emergency vehicle, in case of injury or suspect injury, while the participant is involved in the Summer Camp. I authorize the hospital’s attending physician to administer the necessary emergency professional care to the above named participant upon his/her arrival at the hospital. I understand that while student safety is a high priority under state law, the Fort Bend Women’s Center is not responsible for medical costs associated with a student’s injury.

Media Release: I give permission for Fort Bend Women’s Center, local television stations, and local newspapers to utilize my child’s photo in media releases, Fort Bend Women’s Center’s Website, Facebook Page, Twitter and Instagram postings, and in news broadcasts regarding the Fort Bend Women’s Center Summer Camp Program and related programs for the Women’s Center and the PennyWise Resale Centers.

Signature: Date: Signature: Date:

Printed Name: Printed Name:

………………………………………………………………………………………………………………………………………………

Please return your completed application to the Fort Bend Women’s Center by email, fax or U.S. Mail:

Mailing Address: Fort Bend Women’s Center Fax Number: 281-232-5041

P.O. Box 183E-mail:

Richmond, TX 77406-0005

If you have any questions, please contact Amber Paaso, Volunteer/Outreach Coordinator, at 281-344-5759.

Thank you for your interest Fort Bend Women’s Center’s Violence Prevention Education!

Bringing Hope & Healing to Survivors of Domestic Violence and Sexual Assault

Rev.4/24/15 APaaso