2018-2019 Summer Environmental Educational Camp (Waitlist) 

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Logo and header image
Dear Parent(s) / Guardian(s):  Thank you for your interest in For Love of Children (FLOC).  FLOC provides FREE educational services beyond the classroom to help students succeed from second grade to college and career. FLOC is currently accepting applications for the 2019 Summer for The Environmental Educational Camp.

Please visit this page for more information regarding our programs. You will be contacted with the next steps within two weeks of your student's application being submitted.


Application Checklist

 

In order for your student to be considered for FLOC participation:

  • We must received a completed application
  • We must receive proof of eligibility for free or reduced lunch at school if you filled out a FARM application. Also you can show eligibility for SNAP or TANF, Medicaid card or provide income proof.
  •        Sign and date Health Declaration
  •        Sign and date Terms and Conditions

We must receive the following documents IF your student is receiving supplemental services at school:

  • Individualized Educational Plan (IEP)                      
  • Functional Behavior Assessment
  • Behavior Intervention Plan
  • 504 Plan

 

If you are unable to upload any of the additional documents in this form, please submit them to:

Diana Romero                                          MAIL:                                             SCAN & E-MAIL:      Recruitment & Outreach Manager   1301 Pennsylvania Avenue SE   dromero@floc.org      

FAX: (202) 462-9280                                  Washington, DC 20003             Phone: (202) 349-3517

Yes

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2018-2019 Summer Environment Educational Camp

(SELECT ALL WEEKS YOU WANT YOUR CAMPER TO PARTICIPATE IN)

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CAMPER INFORMATION

CAMPER EDUCATION INFORMATION
Does your camper have any of the following plans to receive supplemental services or accommodations at school?
FLOC INVOLVEMENT

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PARENT / GUARDIAN INFORMATION #1
SECONDARY CONTACT INFORMATION( NOT REQUIRED)
This secondary contact can be additional parent/guardian, relative, neighbor,etc.
EMERGENCY CONTACT INFORMATION (Required - must be someone other than parent / guardian)  
SECOND EMERGENCY CONTACT INFORMATION (Required - must be someone other than parent / guardian)  
STUDENT'S FAMILY BACKGROUND AND HOUSEHOLD INFORMATION
This information will be used to process a camper's application and for FLOC's statistical reports to organizations that make donations to the FLOC program. All of your responses will be kept confidential.
*Please note: If you did not file taxes in 2018, please provide the best estimate of your household income, including TANF, SDI / Social Security, retirement, child support, alimony, etc. 
Number of people
Household Size?

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MEDICAL HISTORY
MEDICAL FORM
I certify that the medical information provided above is accurate to the best of my knowledge. I understand that FLOC will not allow my child to take medications not listed on this form without direct consent from a parent / guardian. I understand that I am required to give medical consent in order for my child to participate in any FLOC program(s).

RELEASE FORM

This form is required. This page MUST be completed and signed by the student's legal parent or guardian

Medical Authorization
I grant permission for a representative of For Love of Children to have my child treated at an appropriate facility in the case of an emergency while my child is in attendance at a For Love of Children program. I understand that representatives of For Love of Children are not medical professionals and will only seek medical assistance from a licensed medical facility in case of emergency when I cannot be reached. I waive my right to prosecute any representative from the program who proceeds as above.
The Senior Staff  and Camp (and their designees) are authorized to dispense prescription medication to students or campers only if the procedures set forth in this policy are followed and the accompanying Medication Release form is completed in full and filed with the Executive Director.

The parent or guardian of the child must provide the appropriate Staff member with a protocol (substantially in the form of the Prescriber Authorization section of the Medication Release) signed by the physician who has prescribed the medication that (1) describes the dosage to be dispensed; (2) the number of times during the day that the medication should be dispensed to the child; and (3) the times of day that the medication should be dispensed. If the medication must be given at precise times or intervals, the protocol should so state.

The parent or guardian must also provide the appropriate Senior Staff with a written request (as set forth in the accompanying Medication Release) authorizing the staff to store and hand the medication to the child and acknowledging that the child is responsible for self-administering the medication and familiar with the manner and mode for doing so. The authorization request must also provide contact phone numbers if we must contact the parent or guardian in an emergency of if the child refuses to take the medication.

All medications must be provided to Camp in their original container and must be clearly labeled with the child’s name and the original prescription attached. Without the foregoing information, Camp staff staff cannot take responsibility for dispensing any medication to students.
Camp will store all medications in a safe and secure location and will dispense the medications in a Camp office, rather than in a classroom. Medications for Camp campers will be held by the Program Directors so that they can be dispensed during field trips and overnights in accordance with the information provided on the Medication Release form. Camp will dispense the medication in compliance with the instructions provided. CAMP WILL NOT ADMINISTER THE MEDICATIONS TO THE CHILD, EVEN IF REQUESTED TO DO SO BY A PARENT OR GUARDIAN.

If the child is uncooperative, Camp will inform the parents immediately. However, Camp reserves the right to refuse to dispense or to continue to dispense medication to any child if the child is repeatedly uncooperative, if Camp is unable to contact the child’s parent or guardian or if compliance with the process otherwise becomes disruptive or overly burdensome to Camp.
Camp staff will maintain a separate file for each child to whom medications are being dispensed, which file will be stored in a safe and secure location. Access to the file will be limited to Senior Staff (or their designees) responsible for dispensing the medication and the Executive Director. The file shall contain the written protocol and parent authorization form. In addition, Senior Staff responsible for dispensing the medication will keep and maintain in the file, a contemporaneous record indicating each dosage of medication dispensed and the date and time the medication was dispensed.

If you have any question feel free to contact us.


Terms and Conditions

The Undersigned participant in FLOC's Environmental Education Program and his or her parent(s)/legal guardian(s) hereby agree as follows:My parent(s)/legal guardian(s) and I hereby agree that we will adhere to all of the rules and regulations of FLOC's Environment Educational Camp including without limitations, the medical procedures established by the Family Camp.

My parent(s)/legal guardian(s) and I hereby understand that we must have family medical coverage for me; and that FLOC's Environmental Education Program will provide full medical coverage at camp for any injuries or illness that may arise during the weeks of the program and are not a result of any preexisting condition. My parent(s)/legal guardian(s) and I further agree that we will bear the cost of my transportation from camp in the the event of illness or if the camp instructor determines, in their sole discretion, that my behavior has violated FLOC's Environmental Education Program Conditions and Regulations to which my parent(s)/legal guardian(s) and I agree, or that I have acted in a manner detrimental to the safety of, or the successful completion of, the Program. My parent(s)/legal guardian(s) and I also agree that we will accept responsibility for me upon my arrival from  Camp, and will pay for any property or other damages that the Camp Instructor have determined were caused by me. In addition, my parent(s)/legal guardian(s) and I agree that if I must return to my place of departure before the completion of the trip, for any of the above reasons, or for any other reason as determined by the Camp Instructor, we will be responsible for the travel expenses to and from my place of origin for an accompanying staff member or medical staff, as deemed necessary by a Camp instructor.

 

My parent(s)/legal guardian(s) and I hereby unconditionally release the sponsoring of FLOC's Environmental Education Program, and any of their officers, directors, executives, employees, agents, volunteers and anyone working under, through or in connection with any of them with respect to any incident, claim, occurrence, loss, injury, or damage that could or may arise out of such participation, including, by way of illustration and not limitation, travel to, from, and within the country; home hospitality; use of any and all facilities used for FLOC's Environmental Education Program or any part thereof; social; cultural and other events (including, by way of illustration and not limitation, trips and educational programs); and any other events or activities in which I may participate or engage, whether or not the same may be deemed to be a part of FLOC's Environmental Education Program or not, from the time when I shall leave my permanent residence until the time when I shall have returned thereto.

 

My parent(s)/legal guardian(s) and I hereby acknowledge that we are executing this instrument with full knowledge of the purpose and effect of the contents hereof, that we have had the benefit of legal advice and counsel of our own choosing, and that we execute the same freely and voluntarily, and on the basis that this instrument cannot be altered or revoked except in a writing approved and signed by me, my parent(s)/legal guardian(s), and an authorized staff member of the Family Camp.

 

By signing below, my parent(s)/legal guardian(s), and I agree to the terms outlined above.


Report Cards, Standardized Test Results, and Education Plans
I grant permission for a representative of For Love of Children to request and receive copies of my child’s report cards, transcript, standardized test results, and supplemental education plans (IEP, behavioral plans, etc.) from my child’s school.
Other Service Providers
I grant permission for a representative of For Love of Children to communicate with other agencies/service providers who are providing assistance to my child, including school counselors, teachers, social workers/case managers, or other non-profit agencies. I understand that FLOC will be communicating with these providers in order to better coordinate services to help my child, and that information about my child will not be shared with anyone outside of the providers, FLOC staff, me, and/or other legal parents or guardians.
OFF SITE TRIPS
I give permission to For Love of Children to escort my child off-site for workshops and excursions (transportation may include use of FLOC van or charter buses).  I understand that the Environmental Educational Program will be outside of drop off and pick up sites daily.
Dismissal From Program
Media, Photography, and Video
I understand and give permission to For Love of Children and approved partners to use information about my student's involvement and progress in program as well as photos or video of my child for use as FLOC deems appropriate for publicity and fundraising purposes. I understand that FLOC will keep my child’s name confidential unless I give permission for use of my child’s first name for publicity purposes (or with photos or video) by answering “Yes” to the following question.
Please note: For Love of Children will contact you directly for permission if we ever wish to use your child's full name (first and last) for publicity or fundraising purposes.
I have read and understand all of the above statements and want my camper to be considered for participation in FLOC.

DC OUT OF SCHOOL TIME FORM

This form is required. This page MUST be completed and signed by the student's legal parent or guardian

FERPA Participant Consent Form
I authorize and consent DCPS Office of the Chief of Staff and/or my child's school to provide information concerning the educatiuon of my child to For Love of Children and United Way of the National Capital Area. I further authorize the release of educational records of my child for the current school year to the parties listed above that include the following information: education transcripts, school/program enrollment information, universal student ID, attendance data, credit history, grades, assessment data, IEP information and graduation attainment (12th grade only). This authorization and release shall remain in effect from August 1, 2018 - July 31, 2019.

By signing below, 1) I acknowledge and understand that I have the opportunity to review the records to be disclosed and the right to challenge the contents of such records; and 2) I am at least 18 years of age or I am signing this document of behalf of my child because he/she is not 18 years of age.                                                                        
OST OFFICE CONSENT
For Love of Children (FLOC) is funded by the Office of Out of School Time Grants and Youth Outcomes (OST Office), a D.C. Government agency through United Way of the National Capital Area. As a grantee we are required to share participant information with the OST Office that may be collected on this form.

In addition, we are required to administer a questionnaire called the Survey of Academic and Youth Outcomes (SAYO). The SAYO is a brief survey with questions about what your child thinks of the program and of the potential benefits from attending the program. All information collected through the SAYO is confidential and no individual child or their individual responses will be identified. Participation in the SAYO is voluntary.

By signing below, I give permission for my child to be included in the SAYO survey. I further authorize For Love of Children to provide name and date of birth to the OST Office.
SIGNATURE
  • I certify that the above information is accurate to the best of my knowledge.
  • I understand that my camper is being considered for admission into For Love of Children program(s) and that submitting this application and attending testing does not guarantee my child a place in any FLOC program.
  • I understand that before my camper will be considered for any FLOC program, I must submit all required documentation (application, report card / transcript, and any applicable supplemental education plans.)