Aaron's Acres Participant Application Form Summer Camp 2017

Application Fee Clause


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Section 1: Participant Information (A Separate Form Must Be Completed For Each Participant.)


In completing this application, you will be asked to select the sessions in which you wish to register.  Please note that if you are interested in applying for an afternoon session you must also apply for the coordinating morning session:   i.e. if you are interested in registering for the AAAOK program, you must register for the older adolescent AM program in the same session, or if you are interested in registering for the A-Team program, you must register for both the morning and afternoon A-Team sessions.

                                       
                                            Please DO NOT use Internet Explorer when filling out this application.





Please Type Date of Birth in the Following Format: MM/DD/YYYY





Section 2: Location, Program, Session, and Session Hours














Primary Parent/Guardian Information (Please enter a parent or guardian with whom the applicant resides)














Secondary Parent/Guardian Information (If Applicable)
















Section 4: Emergency Contact Information

First Emergency Contact 




Second Emergency Contact




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Section 5: T-Shirt and Photo Information


Participant’s Photo: Please provide a recent photo of your child for our camper directory which will be distributed to families on the first day of camp.  Please be sure this is a photo in which our staff will be able to identify your child, as they will also use it to familiarize themselves with your child before the first day of camp.

If you are unable to upload the photo, please send it to

1861 Charter Lane, Suite 114, Lancaster Pa, 17601 (any size is acceptable; we will crop and resize as necessary

Photos needed by April 15, 2017, we cannot guarantee inclusion in the directory if received after this date.


Section 6: Participant's Profile and Medical Information



























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Section 7: Participant Goals

Please select ONE Social/Emotional Goal for your child to work on with our staff while at our camp program. If your child has an IEP or ISP, then please select a social/emotional goal that he/she is already working on within the school or home setting from your child’s IEP or ISP.   Additional comments can be added at the bottom, if needed.

Please choose goal by finishing this sentence:



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Section 8: Permission

The persons listed below have my permission to pick up my child







Please note that a participant’s name, likeness, identity, voice, photographic image, videographic image and oral or recorded statements may be used in printed or electronic marketing and promotional materials, including Aaron’s Acres sponsored websites and social media platforms, participants’ craft projects, memory books, photo galleries on the web site, and group photos and program DVD’s made available to the participating families. As such, the only request for exclusion Aaron’s Acres will now honor is for newspapers and television. By signing below, you are indicating you have read and understand this policy.


I hereby authorize Aaron’s Acres to capture the name, likeness, identity, voice, photographic image, videographic image and oral or recorded statements, or to permit others to do so, of my child for use by Aaron’s Acres in printed or electronic marketing and promotional materials, including, but not limited to, Aaron’s Acres sponsored websites and social media platforms, I release Aaron’s Acres, its officers, agents and employees, from any claim or liability relating to the use of the identified participant’s name, likeness, identity, voice, photographic image, videographic image and oral or recorded statements. I acknowledge that Aaron’s Acres will rely on this consent and release in producing, broadcasting, and distributing materials containing the identified participant’s name, likeness, identity, voice, photographic image, videographic image or oral or recorded statements, and that participants will receive no money or remuneration of any kind from Aaron’s Acres related to this consent and release or the materials covered by this consent and release. I am an adult, 18 years or older, and I have read and understand this agreement and I freely and knowingly give my consent to Aaron’s Acres as described herein.



Notice of Privacy Practices of Aaron's Acres
HIPAA
The HIPAA documentation can be found on our website, www.aaronsacres.org, under the Parent Corner tab. Please take time to read the entire document and then acknowledge with your signature below.

I hereby certify that I have read the Notice of Privacy Practices of Aaron's Acres. I understand that Aaron's Acres may update or amend its Notice of Privacy Practices from time to time, and that I may contact Aaron's Acres directly at any time to obtain a current copy of the Notice of Privacy Practices.


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Section 9: Payment Information

Our camp fees are based on rates given to us by our county funding sources .  They are determined by the staff to child ratio needed for your child at camp.  


After you submit your application form, the administrative staff will determine your child’s ratio and rate. For new families, this will be determined following the intake process.  


If you receive funding from BHDS, CMU, or SAM, please contact your child's Supports Coordinator to discuss the units and funding available for your child.


If you are a self paying family, please contact our Program Director, Elaine Burnett at 717-917-6101 ext 103 to be notified of your child's ratio and cost for camp.


After determining your rate, you will receive an email for your acceptance of the fee.  Your child's application form will be processed AFTER you reply to the email accepting the rate.


At Aaron’s Acres, we have always been committed to providing financial assistance to those families who have needed to explore other payment options.   It is our hope to continue to do so for this coming summer.  If you are interested in being considered for a scholarship, please complete a scholarship request form and submit before the March 31st deadline. The link to the scholarship application will be coming in a follow up email.


Please feel free to contact Elaine Burnett, Program Director, at elaineburnett@aaronsacres.org, if you have questions or wish to explore other payment possibilities.


*** A non refundable application fee of $30.00 is required and must be made payable to Aaron's Acres to secure your child's placement in the program.  After you submit your application form, you will be led to a click and pledge page where you will have the opportunity to pay this non refundable fee at this time. If you are unable to make an online payment, please mail a check to our administrative office at 1861 Charter Lane, Suite 114, Lancaster, PA 17601 to begin the application process.***

 



Outside Funding Information







        A limited number of scholarships are available. Please complete the scholarship form as soon as possible if you need financial assistance.  You can find the link to the Scholarship Request form on the Home page of our website, www.aaronsacres.org.  All requests for scholarship must be made by March 31, 2017.

After submitting this form, you will be directed to an online registration payment page.  This page is ONLY for the $30 application fee.  No other fees associated with your child's registration should be paid online at this time.  If you do not wish to pay online, simply close out your browser when you have been redirected to the payment page. 

If you wish to mail the registration fee along with any other payments, send to:

Aaron's Acres

1861 Charter Lane, Suite 114

Lancaster, PA 17601


***PLEASE NOTE THAT THE APPLICATION WILL NOT PROCESSED

UNTIL WE RECEIVE YOUR $30.00 APPLICATION FEE***

Volunteering
At Aaron’s Acres, we firmly believe that the spirit and commitment of our volunteers form the lifeblood of our organization. Without the tireless efforts of our volunteers, we wouldn’t be where we are today.

If you have any questions regarding volunteering in any of the capacities listed below, please contact Risa Paskoff  at risapaskoff@aaronsacres.org.

Please select one or more areas where you might have an interest:


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