SUMMER YOUTH PROGRAM APPLICATION

PARENTS: This paperwork enrolls your student in Caldera’s year round program, July2013-July 2014

Camp Session: DISCOVERY
 Discovery: August 9th – 16th (eligible for students starting 7th, 8th or 9th grade in 2013)
Enrollment Priority

Enrollment is limited to 60 campers per session. We receive many more applications than we can accept, but because we are committed to developing lasting relationships with young people, every application is carefully considered.

Need Criteria (considered in this order):

  • Qualification for the Free and Reduced Lunch Program (required of all new applicants)
  • Lack of access to the arts
  • Lack of access to outdoor experiences

Personal Criteria:

  • Supportfrom a Caldera Arts Partner School or Referring Partner Agency
  • Must have completed grade 6, 7 or 8
  • Committed to weekly school mentor sessions (middle school)
  • Committed to attending Saturday workshops; at least one a month (high school)
  • Interest in the arts
  • Curiosity about the outdoors
  • Willingness to try new things and push personal limits
  • Attendance at weekend intensive workshopswhen offered in Fall and/or Spring (all ages)
Application Instructions
Applicants are encouraged to be thorough and thoughtful in their responses.Completedapplications should be returned to:
Caldera
Attention: Summer Program Application
224 NW 13th Avenue, Box 304
Portland, OR 97209
Fax: 503.937.4855
Application Deadlines:
  • Please return completed applications byApril 19th, 2013; if you have missed this deadline please call to see if there are still spaces available: 503-937-7594
  • These completed forms, along with payment of a non-refundable $35 commitment fee, are required to reserve a space at camp. Scholarships are available. If you have any questions, please contact Alisha Miller, at 503-937-7594 or
  • Acceptance notifications and camper handbookswill be mailed to applicant’s home beginning on April 22rd, 2013.

Caldera does not discriminate on the basis of race, color, national origin, sex, religion, age or physical ability.

Summer Youth Program Application

Student Personal Information

Name First: Last: Camp Name:
Address: Apt. #:
City: State: Zip Code:
Home Phone: Parent/Guardian Cell:
Student Cell: Work Phone:
Student E-mail: Parent/Guardian E-mail:
Best way to contact you: Mail  Parent Cell  Home Phone  Student Cell Work Phone Parent Email  Student Email Other:______
I give permission for Caldera to contact my student by: Texting Facebook MySpace  Email  Cell
Age on 6/1/13: Date of Birth: / /
Ethnicity(mark all that apply): African-American American Indian/Alaskan Native  Asian  Caucasian
 Hispanic  Multi-racial  Native American/Pacific Islander Other:______
Primary language spoken at home:  English  Spanish  Chinese  Russian  Vietnamese
 Other______
Gender: In 2013 my child will be entering grade:
 Male  Female 7 8 9 10 11 12 GED College ______
Current School: 2012-13 School:
Have you attended Camp Caldera before?  Yes  No
If yes: Circle the years: 2009 2010 2011 2012 Other:
If accepted, are you able to commit to participating in our program all year long including weekly sessions (middle school), once a month Saturday activities (high school) and intensive weekend retreats?
 Yes  No  Not sure

- 1 -

Parent/Guardian emergency Contact information

Student lives with : both parents/guardians 1st parent/guardian 2nd parent/guardian Other
1st Parent/Guardian
Name:
Home Phone: / Work Phone: / Cell Phone:
2nd Parent/Guardian
Name:
Home Phone: / Work Phone: / Cell Phone:
Emergency Contacts:
Name:
Home Phone: / Work Phone: / Cell Phone:
Name:
Home Phone: / Work Phone: / Cell Phone:

Caldera does not discriminate on the basis of race, color, national origin, sex, religion, age or physical ability.

HAVE YOUR PARENT/GUARDIAN COMPLETE THIS FORM.

Parent/Guardian Information

(To be completed by legal guardian)
Name (please print) First: Last:
Relationship to applicant:
Daytime phone: Evening phone:
Is the applicant in foster care?  Yes  No
If your address is different than the applicant’s, please indicate where you would like us to mail camp information:
Applicant’s approximate age of developmental/emotional maturity: _____
Does the applicant require full-time supervision? Yes No 
Does the applicant have a history of:
Running away: Yes No  / Attempted suicide: Yes  No  / Mental health issues: Yes  No 
Acting out sexually: Yes  No  / Substance abuse: Yes  No  / Physical or sexual abuse:
Yes No 
Involvement with the justice system: Yes No 
Please use the space below to explain any items checked “Yes” and tell us more about the applicant. It is essential upon you as the parent/guardian to provide us with any information that may help determine whether the applicant is appropriate for this program. Please include any special accommodations the applicant may need at camp. If you have any concerns, or would prefer to discuss this information over the phone, please call Alisha Miller 503-937-7594.
Is the applicant eligible to participate in the Free and Reduced Lunch Program? Yes  No
Number of people in your household: Annual Household Income:
Why would the applicant benefit from attending Caldera? If your child is a returning camper, what changes have you seen since s/he joined Caldera?

Parent/Guardian signature ______Date ______

Please send completed applications by mail or fax to: Caldera

Attention: Summer Program Application

224 NW 13th Avenue, Box 304

Portland, OR 97209

Fax: 503.937.4855

Please return completed APPlications by April 19th, 2013; if you have missed this deadline please call to see if there are still spaces available. These completed forms, along with payment of a non-refundable $35 commitment fee, are required to reserve a space at camp. Scholarships are available. If you have any questions, please contact Alisha Miller, at 503-937-7594 or Accepted campers will receive a packet of forms which must be completed and returned, along with a non-refundable $35 commitment fee to confirm a space at camp. Scholarships are available.

QUESTIONS FOR THE MIDDLE SCHOOL DISCOVERY APPLICANT

You should know that many more students apply than we can accept. Your careful thought in answering the following questions is important to your application. Also, your behavior, participation and attendance in your weekly school sessions play a significant role in the decision-making process. Applicants who show a strong desire and commitment to try new things are ideal for the Discovery Program.

This portion of the application MUST be completed by the student. Use an extra sheet of paper if you need additional space for your answers.

1) Why do you want to be a part of this program?

2) Please list any art classes you have taken (example: music, writing, photography, theater, painting)

3) List three of your personal strengths.

4) Tell us about the people who live in your home.

5) What outdoor experiences have you had? Do you like the outdoors?

6) Describe the last time you tried something new. Were you scared? Did you feel successful?

7) Out of all of the applicants, why should you be selected?

Applicant Signature ______Date ______

- 1 -