Camp St. Vincent Intake Form

Camper Details

First Name

Last Name

Camper Birthdate (e.g. 1/1/1900)

Gender

Race

Ethnicity

Alumni Status

Shelter of Residence

Please enter the dates your child will be unable to attend camp.

School Details

Name of School Attended in 2023 - 2024

Current Grade Enrolled as of June 2024

Baltimore City School ID (optional)

Health

Please enter N/A if there is no response.

Food Allergies

Medication Allergies

Other Allergies

Have Asthma?

Any additional health problems?

Description of Health Problems

Child currently taking medication? If yes, please provide details below.

Please include dosage, medication times, and any additional information.

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Adult Contact Details

Parent/Guardian Name

Home # of Parent/Guardian

Work # of Parent/Guardian

Cell # of Parent/Guardian

Emergency Contact Name

Emergency Contact Home #

Emergency Contact Cell #

Transportation Details

Person with permission to pick child up

Transportation Phone #

Each applicant is required to complete parent/guardian and opt-in online consent form(s). Please proceed to the next page to complete.

PARENT/GUARDIAN CONSENT AGREEMENT

Please provide your response for each statement below for consent/agreement:

Photo Consent: I hereby give permission for St. Vincent de Paul of Baltimore to photograph, film, videotape and/or make sound recordings of my child, to quote or publish statements of my child, and to use such photographs, films, videotapes, sound recordings and/or other statements for informative, educational and promotional/advertising materials. I understand that my child may be identified in any of these materials, and that any such photographs, films, videotapes, sound recordings and/or written works are the property of St. Vincent de Paul of Baltimore and that neither my child nor I am entitled to any compensation for or rights to these materials. I release St. Vincent de Paul from all liability with respect to the matters covered by this release.

Health History Consent: The health history provided is correct so far as I know, and the participating child has permission to engage in all prescribed program activities. I hereby give permission to medical personnel to administer first aid.

Sunscreen Consent: During the course of the summer, children may be exposed to excessive sunlight. I hereby give permission for program personnel to apply sunscreen lotion (cream or spray) to the skin of my child prior to exposure to sunlight. If NO, please ensure any allergies or sensitivities have been identified on the first page of this application.

Attendance Consent: I understand that if my child misses 3 days without prior notification (via in writing or phone call to the program office) the child will be unenrolled for any upcoming sessions.

Medical Consent: I hereby give permission to the medical personnel selected by the Camp St. Vincent program director to order x-rays, routine tests, treatment to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization of the person named on the application.

Baltimore City Schools Data Sharing Consent: I hereby give permission for St. Vincent de Paul of Baltimore to share my child's demographic and assessment data with Baltimore City Schools.

St. Vincent de Paul of Baltimore (SVDP)
Camp St. Vincent (CSV) Program Evaluation

CONSENT TO PARTICIPATE

Dear parent or caregiver,

Your child is participating in 2024 Camp St. Vincent. As part of your participation, St. Vincent de Paul of Baltimore utilizes external evaluators to conduct an evaluation of our program. The information gained from the evaluation will provide St. Vincent de Paul of Baltimore and Camp St. Vincent leadership with information about the effectiveness of the program with respect to improving and reinforcing student academic development and performance and social-emotional well-being. We are asking for your permission to include your child in the evaluation.

Your permission will grant Camp St. Vincent’s evaluator the ability to request data from Baltimore City Public Schools including but not limited to: student identification number, academic information, attendance records, and background/demographic information. This information will be kept confidential and will be used for evaluation purposes only. All reporting results for evaluations will be anonymous and no identifying information will be disclosed in order to ensure your child will not be identified.

We hope that you will allow your child to participate in this important evaluation!

Note: Permission is optional, and your child's participation in Camp will not be affected.

Student

School Name

Student BCPSS ID Number

(Requested to facilitate process of identifying students by City Schools as part of the data request process.)

Student Name

Consent Option

Please Select One:

My child MAY participate in the CSV Program EvaluationMy child MAY NOT participate in the CSV Program Evaluation

Parent/Guardian Name/e-Signature

Name:

Date:

Contact Information

Camp St. Vincent Intake Form

St. Vincent de Paul of Baltimore (SVDP) Camp St. Vincent (CSV) Program Evaluation CONSENT TO PARTICIPATE

St. Vincent de Paul of Baltimore (SVDP)
Camp St. Vincent (CSV) Program Evaluation

CONSENT TO PARTICIPATE