Camp Remember Me Family Application
You must submit a refundable $100 deposit to complete your application in person or by mail. ONLY CASH OR CHECK WILL BE ACCEPTED. Make check payable to the WARM Place. Your deposit will be returned on the first day of camp.

Basic Information (please print):
Parent/Guardian’s Name (First and Last):	 	

Street address	City/State	Zip

Phone Number	Email

Honored Loved One’s Name & Relationship to the Children: __________________________________________________

Current WARM Place Group Night: __________________________________________________________________________

Please include names of all family members attending camp. 
T- Shirt Sizes available are: Adult: AXXL, AXL, AL, AM, AS   Children: YS(2-4), YM(6-8), YL(10-12), YXL(12-14)

First and last name of every family member attending camp	Camper’s         gender	Camper’s age         	Camper’s T-Shirt Size 
(circle below)	
			YOUTH: YS  YM  YL  YXL
ADULT: AS AM AL AXL AXXL	
			YOUTH: YS  YM  YL  YXL
ADULT: AS AM AL AXL AXXL	
			YOUTH: YS  YM  YL  YXL
ADULT: AS AM AL AXL AXXL	
			YOUTH: YS  YM  YL  YXL
ADULT: AS AM AL AXL AXXL	
			YOUTH: YS  YM  YL  YXL
ADULT: AS AM AL AXL AXXL	
			YOUTH: YS  YM  YL  YXL
ADULT: AS AM AL AXL AXXL	
			YOUTH: YS  YM  YL  YXL
ADULT: AS AM AL AXL AXXL	
			YOUTH: YS  YM  YL  YXL
ADULT: AS AM AL AXL AXXL	

Pajama sizes for children ONLY:

Child’s Name	Pajama size (circle below)	
	YOUTH: YXS(4/5)  YS (6)   YM (7/8)    YL (10/12)    YXL (14/16)
ADULT:    AS       AM      AL    AXL    AXXL	
	YOUTH: YXS(4/5)  YS (6)   YM (7/8)    YL (10/12)    YXL (14/16)
ADULT:    AS       AM      AL    AXL    AXXL	
	YOUTH: YXS(4/5)  YS (6)   YM (7/8)    YL (10/12)    YXL (14/16)
ADULT:    AS       AM      AL    AXL    AXXL	
	YOUTH: YXS(4/5)  YS (6)   YM (7/8)    YL (10/12)    YXL (14/16)
ADULT:    AS       AM      AL    AXL    AXXL	

EMERGENCY CONTACT INFORMATION

Please provide emergency contact information for two trusted individuals who will not be attending camp: Name:	 Relationship:  	
Home Phone Number: _________________	                       Cell Phone Number:       	__________________________                                             
        
Name:	 Relationship:     	  

Home Phone Number:	              Cell Phone Number:                                                            	

MEDICATIONS: You are responsible for bringing to Camp Remember Me any daily and as needed prescription medications, as well as potential over-the-counter medications that your family will need. All prescription and OTC medications must be kept in their original containers with labels. Place all medications in a gallon bag with your last name written legibly on the front.  Medication baggies will be kept at the health center. We ask that if anyone in your family regularly takes ADHD medication, or any other psychiatric medication in order to attend work or school, that you take this medication while at Camp Remember Me. At camp, the health center will have available Benadryl cream, Neosporin cream, Band-Aids, Pepto-Bismol, Tylenol, Advil/Aleve, and Benadryl.

 	(Initial) I have read the above section on medication and understand that I must bring my own prescription and non- prescription medication and the limits of what will be available in the health center.

AUTHORIZATION AND CONSENT OF MEDICAL TREATMENT FOR CAMP PARTICIPANTS

I grant my authorization and consent for The WARM Place to administer general first aid treatment for any minor injuries or illnesses experienced by individuals listed on page 1 of this registration. If the injury or illness is life threatening or in need of emergency treatment, I authorize The WARM Place to summon any and all professional emergency personnel to attend, transport, and treat my family and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume fiscal responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of The WARM Place in the exercise of their best judgment upon the advice of any such medical or emergency personnel.
This authorization is effective through November 30,2023
Signature:  			
Printed Name:	 Date: 	

THE WARM PLACE: CAMP RELEASE FORM
INFORMED CONSENT
I recognize that certain hazards and dangers are inherent in camp activities. I acknowledge that although The WARM Place Camp Remember Me and Camp El Tesoro have taken safety measures to minimize the risk of injury to camp participants, The WARM Place Camp Remember Me and Camp El Tesoro cannot insure or guarantee that the participants, equipment, premises or activities will be free of hazards, accidents or injuries. I understand all health issues are my responsibility. It is my responsibility to seek and obtain appropriate care for any health problems experienced by my family including medication, first aid, and emergency care. I understand that all medications must be turned into The WARM Place staff upon arrival at Camp El Tesoro. All medications will be stored in a locked room in the Health Facility.
I have read Camp El Tesoro’s Rules and Regulations and Camp Guidelines. I agree that my family and I will comply with these Rules and Regulations/Guidelines. I understand the camp staff consists mostly of volunteers, not professional therapists. I understand that for group activities, confidentiality is observed and that individuals must respect the privacy of other group participants by not discussing the issues of others outside the group.

LIABILITY RELEASE
I, the undersigned, understand that occasionally accidents occur during camp activities and that participants may sustain serious personal  injury and property damages as a consequence thereof. Knowing the risks of camp activities, nevertheless, I agree to assume those risks and by signing this liability release, I intend to legally bind myself, my minor children, my heirs, executors, and administrators. I hereby release and forever discharge The WARM Place and Camp El Tesoro, and any of their officers, directors, employees, and agents from all claims, causes of action or damages arising out of any injury(ies), illness, or loss of any kind, known or unknown, including but not limited to injury(ies) to property or person, to me and my family during or related to our attendance at The WARM Place Camp Remember Me at Camp El Tesoro.

MEDIA RELEASE
I, the undersigned, understand that this authorization permits The WARM Place to take and use photographs and/or films (including film photography, digital photography, cinematography and videography), artwork, and audio of my family and I. I understand that photographs, video, films, audio, and artwork may be taken individually or as a part of a group. I also understand that in order to give participants access to these photographs and/or videos, they will be uploaded to The WARM Place social media accounts.  

I understand and agree these photographs, films, (including photography, digital photography, cinematography, videography), artwork, and audio may be used by The WARM Place staff and representatives for any of the following purposes: educational, information, training, social media, promotional, fundraising or any other purpose deemed appropriate by The WARM Place including, but not limited to website/social media, videotapes, pamphlets and/or brochures. The WARM Place may use these photographs, and/or films, artwork, or audio without compensation of any kind to the person(s) named in this The WARM Place: Camp Release Form.

By signing this release, I intend to legally bind myself, my minor children, my heirs, executors, and administrators. The WARM Place shall have the right to use the photographs, other images of me and my family listed below, artwork, and audio in educational, promotional, or fundraising materials and to upload the photographs, other images of me and my family listed below, artwork, and audio to various social media platforms of The WARM Place. I acknowledge that The WARM Place will have all rights of copyright in and to such photographs, videos, audio, and artwork and may use such copyright fully. I also release The WARM Place and it’s officers, directors, agents, and employees from all liabilities connected with the taking and use of these materials as is authorized by The WARM Place. In addition, I waive all rights or claims for payment in connection with any exhibition or release of these materials. This consent is voluntary, and I give it in the interest of public information, education, the furtherance of the goals of this institution or other lawful purposes.

I hereby acknowledge that I have read the above consents and I understand its contents and agree to the terms set forth therein for all family members listed on page 1 of this registration.

First and Last Name of Every Family Member Attending Camp:

 	
Signature of Parent/Legal Guardian	Date

 	
Signature of Parent/Legal Guardian	Date

Printed Name of Person Signing