Happy Trails will have two summer camp sessions again this summer. Each child may only
attend one session. Summer camp is for children ages seven to twelve Exceptions are made
only for previous campers, who are all welcome to attend after age 12. This year, older
campers (ages 13-15) can attend either week of camp. Campers who are 16 years or older can
only attend camp if selected as a Junior Counselor.
New campers must be 7-12 years old, have an open case in the
California foster care system and provide a case number on the
application.
Space at camp is limited. Registration is on a first come, first served basis for all
campers based on availability in cabins. We will confirm receipt of your application and
notify you if your application is complete or incomplete.
Campers are not enrolled in summer camp until you receive a confirmation packet.
Confirmation packets and waitlist notifications
will be emailed/mailed on Friday, May 15, 2015.
If your camper is waitlisted for camp, we will contact you by June 19, 2015 with any updates.
Please return ALL necessary documentation with required signatures
Via Mail
Via Fax or Email
Happy Trails for Kids
2525 Ocean Park Blvd,
Suite 104
Santa Monica, CA 90405
FAX: 888-741-5297
[email protected]
Questions ??
Please contact us at 310-650-5943 or [email protected]
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
2
2015 CAMPER REGISTRATION FORM
SESSION PREFERENCE
THIS APPLICATION IS FOR (**Each camper can only attend one session**):
Session 1 (June 21 – June 26, 2015)
**PLEASE NOTE THAT CAMP DAYS
Session 2 (June 28 – July 3, 2015)
HAVE CHANGED! CAMP WILL TAKE
No preference (Happy Trails will assign a session)
PLACE FROM SUNDAY TO FRIDAY.
CAMPER INFORMATION
FOR NEW CAMPERS: Registration will not be processed without a case number
ORIGINATING COUNTY:
Imperial
Los Angeles
Orange
Riverside
San Bernardino
San Diego
Ventura
Other:
CASE NUMBER ___________ (MANDATORY FOR NEW CAMPERS)
Last Name
First Name
Returning camper
New camper with foster sibling(s) in program
Middle Name
New camper with biological sibling(s) in program
New camper
Address:
City:
State:
Zip:
Home Phone:
Date of Birth:
/
/
Age
(New campers must be 7-12 years ONLY)
Ethnic Group (optional):
African American
Caucasian
Gender:
American Indian
Latino
Male
Female
Asian & Pacific Islander
Other:
For NEW or relocated campers only - Will your camper need a sleeping bag?
T-Shirt:
Youth Small
Youth Medium
Adult Small
Adult Medium
Adult Large
YES
NO
Adult XL
Adult XXL
GUARDIAN/CARETAKER INFORMATION
Last Name
First Name
Primary Phone
Middle Name
Secondary Phone
Email: __________________________________
Who does the camper currently live with?
Non-relative extended family member
How long has the camper lived with you?
Foster home
Relative
Less than 1 month
1-2 years
Has the court appointed you as the camper’s legal guardian?
Have you legally adopted the camper?
Group home
Other:
Yes
What is the primary language spoken at home?
No
English
2–6 months
3 – 5 years
Yes
No
Parent
6-11 months
5+ years
N/A
N/A
Spanish
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
Other:
3
Camper’s Name:
Are you applying for any other returning or new campers to this camp?
Yes
No
Name:
Gender:
Male
Female
Age:
Name:
Gender:
Male
Female
Age:
Name:
Gender:
Male
Female
Age:
Name:
Gender:
Male
Female
Age:
How did you hear about this camp?
If you are part of an FFA, what is the name?
FFA Worker Contact Information
Name
Phone
DCFS Social Worker Contact Information
Name
Phone
LIABILITY RELEASE & PERMISSIONS
Note – Pursuant to Welfare and Institutions Code §362.05, caregivers may provide permission for a child residing in foster
care to participate in extracurricular, enrichment and social activities.
I have reviewed all of the information provided to me by Happy Trails for Kids and Happy Trails
Camp (together referred to as “Happy Trails”). I give permission for my child (or ward) to
participate in all camp activities and events with Happy Trails. I understand that by virtue of
participation, my child (or ward) may risk bodily injury, death and/or other loss, including damage to
property. I knowingly and freely assume all of such risks that my child (or ward) may incur from
participation in camp activities and special events. On behalf of myself and my child (or ward), I
release and hold harmless Happy Trails, and its officers, directors, employees, volunteers, agents,
contractors and subcontractors, with respect to any and all claims, losses and damages of any kind,
except for those arising from gross negligence or willful acts.
I understand that reasonable measures will be taken to safeguard the health and safety of all
participants and that I will be notified as soon as possible in the case of any emergency affecting my
child (or ward). In the event that I cannot be reached, I authorize Happy Trails and/or the
emergency contacts provided by me to act on my behalf and to take any and all steps deemed
necessary to protect such health and safety.
I understand that if my child (or ward) cannot complete the camp program due to homesickness or
behavioral issues, Happy Trails staff will provide transportation from camp to Temecula but I am
required to arrange for transportation to pick-up my child (or ward) in Temecula within
six hours of notification. I also understand that the registration fee is non-refundable.
Caretaker/Guardian Signature
Date
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
4
Camper’s Name:
REGISTRATION FEE & INFORMATION
*** A $50 FULLY REFUNDABLE deposit is required to complete
your camper’s registration with Happy Trails***
In the past, we have had a large waiting list and a number of applicants did not show up the day of
camp. In order to avoid this and to make sure we have all of our spots filled, we are requiring a
refundable deposit. This means that every camper’s application must include a $50 deposit. As detailed
below, you will receive a refund in the full amount:
If your camper is selected to attend summer camp and attends on time.
If your camper is waitlisted for camp and cannot attend due to space limitations in the cabins –
deposits will be refunded after Friday, June 19, 2015.
If your camper is selected to attend but cancels registration by the deadline – the deadline to
cancel without penalty is Friday, June 5, 2015.
HOWEVER, IF YOUR CAMPER RECEIVES A CONFIRMATION AND DOES NOT ATTEND
CAMP, THEN YOU WILL BE CHARGED $50.
PAYMENT MUST BE RECEIVED TO COMPLETE APPLICATION
Happy Trails must receive payment in order to complete your camper’s application. If you return this
application via fax without credit card information, your application will not be processed until payment
is sent to the address listed below. If paying via check, please send a separate check for each camper.
Payment Method: (Please mark one)
Cashier’s Check or Money Order (you will be sent a full refund subject to the terms described above).
Check # ________ (Make checks payable to: Happy Trails for Kids. Checks will not be cashed and
will be returned subject to the terms described above.)
Credit card (Your card will not be charged subject to the terms described above).
Name on Card____________________________
Billing Address:
City:
State:
Zip:
Billing Phone Number:
VISA/ MASTERCARD/ AMEX #__________________________________________________
CVV (3-digit # on back of card)______________________ Exp. Date___________________
Signature ___________________________________________
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
5
Camper’s Name:
EMERGENCY CONTACT INFORMATION
**REQUIRED** Please list at least two individuals (over the age of 21) OTHER THAN THE
GUARDIAN/CARETAKER to contact in case of an emergency if you cannot be reached.
Name:
Relationship to camper:
Primary Phone
Secondary Phone
Name:
Relationship to camper:
Primary Phone
Secondary Phone
TRANSPORTATION
Happy Trails for Kids will be providing transportation for your child (or ward) to and from camp, and also
for some special events during the year. Your child (or ward) must be at the assigned pick-up location
on time and will return from the trip to the same location.
I authorize the following person/s IN ADDITION TO MYSELF to pickup my child (or ward):
Name
Primary Phone
Relationship to Child
Name
Primary Phone
Relationship to Child
ADDITIONAL CAMPER CARE INFORMATION
This is a confidential application – please provide any additional information about your camper’s
behavioral/emotional needs or life experiences that will help us provide the best care at camp. Does
your camper have any problems at night (sleepwalking, bedwetting, etc.)? Are there any restrictions on
your camper’s activities? Does you camper have any fears that we should be aware of at camp?
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
6
Camper’s Name:
MEDICAL INSURANCE INFORMATION
The camper is covered by medical insurance?
Insurance Company
Subscriber
Yes
No
Policy Number
Insurance Company Phone
IMMUNIZATIONS (Please complete this section or attach copy of immunization record.)
Is copy of immunization record attached?
Yes
Vaccine
Dates: Mo/Yr
DPT (Diphtheria, Tetanus, Pertussis)
Tetanus booster
MMR (Mumps, Measles, Rubella)
Haemophilus influenza type B (HIB)
Tuberculosis (TB) Test:
Date of last test
No
Polio
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Result:
Positive
Negative
ALLERGIES
No known allergies
Camper is allergic to (please check all that apply):
Food
Medicine
Environment (insect stings, hay fever, etc.)
Other
Please describe the allergy and the camper’s physical reaction below:
DIET/NUTRITION
Camper has special food needs. Please describe below:
Camper eats a regular diet.
GENERAL HEALTH HISTORY
Please answer the questions to the best of your knowledge – has/does the camper:
Have a history of nose bleeds?
Yes
No
Have recent/chronic illnesses or injury?
Yes
No
Had asthma/wheezing/shortness of breath?
Yes
No
Have diabetes?
Yes
No
Had seizures, headaches, fainting or dizziness?
Yes
No
Have problems sleepwalking/nightmares?
Yes
No
Have a history of bedwetting?
Yes
No
Have problems with diarrhea or constipation?
Yes
No
Have any skin problems?
Yes
No
Ever been treated for an eating disorder?
Yes
No
Have any restrictions for participating in activities?
Yes
No
Please explain any “Yes” answers:
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
7
Camper’s Name:
MEDICATION
NON-PRESCRIPTION MEDICATIONS
PLEASE MARK ALL MEDICATIONS THE CAMPER CAN TAKE. The following medications may be
stocked with the Camp Nurse and are used on an as needed basis to manage illness and injury. By
marking the medications that the camper can be given, you are authorizing designated
camp personnel to provide routine health care and administer non-prescription medications
as necessary.
WHICH MEDICATIONS CAN WE GIVE THE CAMPER, IF NEEDED?
NONE
Acetaminophen (ie: Tylenol)
Aloe
Antibiotic cream (ie: Neosporin)
Antihistamine/allergy medication
Calamine lotion
Cough drops/syrup
**********************************************************************************
PRESCRIPTION MEDICATIONS
Note – “Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins.
Please remember that you will need to provide enough of each medication to last the entire time the camper will be at camp.
All medication must be in the original container with the original label listing your camper’s name and doctor’s instructions
(including inhalers). All medication will be kept by the Camp Nurse and will be returned at the end of camp.
The camper will not take any medications while attending camp.
The camper will take the following medication(s) while attending camp.
Name of
medication
Date Started
Reason for
taking
medication
When is the
medication
given?
Breakfast
Lunch
Dinner
Bedtime
Other (explain):
Breakfast
Lunch
Dinner
Bedtime
Other (explain):
Breakfast
Lunch
Dinner
Bedtime
Other (explain):
Caretaker/Guardian Signature
Date
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
Amount or dose
given
How is the
medication
given?
8
CAMPER BEHAVIOR CONTRACT
Please complete this portion with your camper.
I will try my best to get along with the other campers and staff at camp and will show respect
for others’ personal belongings, privacy and feelings.
I will not use inappropriate language or profanity.
I will try all of the camp activities to the best of my ability.
I will keep my cabin and other areas in camp clean and I will not go into other people’s
belongings or any cabins other than my own.
I will not bring items that aren’t allowed to camp. I know that this includes cell phones,
IPODs, matches, fireworks, medicine, food, gum or candy.
I will stay with my group at all times and will not leave my group or camp without permission.
I will not leave my cabin after “lights out” at night.
If I am hurt or do not feel well I will tell the nearest adult as soon as possible so that they can
help me feel better.
I know that if I see someone else break the rules or get hurt it is my responsibility to tell an
adult right away.
I know that all medications will be kept by the nurse who will give them to me if I need them.
I know that I cannot call home during the week, but I can send letters home if I want to.
I know that if I do not follow the rules I will be given timeouts from activities. I can also be
sent home early from camp and my caretaker/guardian will have to come and pick me up.
Camper Name
Camper Signature
Date
Caregiver/Guardian Name
Caregiver/Guardian Signature
Date
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
9
MEDIA RELEASE (THIS IS AN OPTIONAL RELEASE)
I DO NOT approve the media release for my child (or ward) at Happy Trails
______________________________
Printed Name of Guardian/Caretaker
______________________________
Printed Name of Camper
______________________________
Signature of Guardian/Caretaker
______________________________
Date
OR
I DO approve the media release for my child (or ward) at Happy Trails
This section needs to be completed by the Camper – please initial each section:
__________ I understand that there is a chance somebody may take my picture, video me, record
something I say or write about me.
__________ I understand that people outside of camp could see these pictures, videos, recordings
and/or writings. They could be in things like the news, the camp website or brochures for the camp.
People would know that I am part of the foster care system.
__________ I understand that I have the right to say they can’t use any pictures, videos, recordings
and/or writings of or about me.
__________ Even though I have the right to say no, I am giving Happy Trails for Kids Summer Camp
permission to use any pictures, videos, recordings and/or writings of or about me.
Camper Signature
Camper Name
Age
Date
This section needs to be completed by the Caregiver/Guardian:
I have ensured that the camper I am enrolling has read and understood the terms of this media release.
I hereby give Happy Trails for Kids, together with its legal representatives and assigns, the right and
permission to publish, without charge, photographs or videotapes taken during the camp session where
the camper may appear. These photographs or videotapes, together the camper’s name and/or
biographical information, may be used in publications, websites, audio-visual presentations, promotional
literature, advertising, public media or in any other manner.
Caregiver/Guardian Name
Caregiver/Guardian Signature
Date
Sometimes we have campers call us after camp to get in contact with friends or staff. Can we share
your child (or ward’s) contact information with other campers?
YES
NO
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org
10
CAMPER QUESTIONNAIRE
Please answer these questions with your camper.
1. Camper’s name:
Age:
Gender:
BOY or
GIRL?
2. Camper’s nickname:
3. Camper’s favorite color?
4. What are your camper’s favorite activities or interests?
5. Has your camper been to residential summer camp before?
6. Does your camper know how to swim?
YES or
YES or
NO
NO
7. How is your camper feeling about going to camp for a week?
8. What is your camper most excited to do at camp?
9. Please list any additional information that will be helpful in making camp an enjoyable experience for
your camper.
2525 Ocean Park Blvd, Suite 104
Santa Monica, CA 90405
Phone: 310-452-7979 FAX: 310-452-5151
www.HappyTrailsForKids.org