Camp St. Vincent Intake Form
Camper Details
First Name
Last Name
Camper Birthdate
Gender
Please select...
Male
Female
Declined to answer
Race
Please select...
Black or African American
White
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Declined to answer
Ethnicity
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Hispanic or Latino
Non-Hispanic/Latino
Declined to answer
Alumni Status
Please select...
2020 Alumni
2019 Alumni
2018 Alumni
2017 Alumni
New camper
Declined to answer
2021 Alumni
Shelter of Residence
Please select...
Booth House(Salvation Army)
Christ Lutheran(Balto.Outreach)
Cottage Avenue
Dayspring
Druid Heights Community
Eastern Family Res. Center
Family Crisis Center
Gaudenzia
Geraldine Young Family Life Ctr.
House of Ruth
INNterim-Sudbrook -
Marian House Gorsuch
Marian House York
Night of Peace Shelter
Pratt House
Rutland-Lanvale Transitional
Sage House
Sarah's Hope
Sarah's Hope-Hannah More
Sarah's Hope-Mount Street
Women's Housing Coalition
YWCA- McCullough
YWCA- Suzanna Wesley
Select all the weeks of camp your child will be unable to attend. (select all that apply)
Please select...
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
My child is able to attend ALL sessions
Photo consent
Please select...
Yes
No
Declined to answer
School Details
Name of School Attended in 2021 - 2022
Current Grade Enrolled as of June 2022
Please select...
Has not yet attended school
Pre-K
K
1
2
3
4
5
6
7
8
Not Enrolled
Declined to answer
Select All
Baltimore City School ID (optional)
Health
Please enter
N/A
if there is no response.
Food Allergies
Medication Allergies
Other Allergies
Have Asthma?
Please select...
Yes
No
Declined to answer
Any additional health problems?
Please select...
Yes
No
Declined to answer
Description of Health Problems
Child currently taking medication? If yes, please provide details below.
Please select...
Yes
No
Declined to answer
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:
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.
Please select...
Yes
No
I hereby authorize the SVDP Program to have and use photographs and video of the child named on this application as may be needed for its records or public relations purposes. I understand the child named on this application may have his/her picture taken for publication in the local newspaper and video clips may be used for the local news.
Please select...
Yes
No
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.
Please select...
Yes
No
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.
Please select...
Yes
No
I hereby give permission to the medical personnel selected by the SVDP 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.
Please select...
Yes
No
Please complete the OPT-IN/OUT Form
below.
Upon completion of the OPT-IN Summer Funding Collaborative Form, please click SUBMIT at the bottom of this page or your application
WILL NOT
be sent!
ONLINE CONSENT FORM [ENGLISH]
ONLINE CONSENT FORM [SPANISH]
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Contact Information