Summer camp application, youth with social challenges

When is the next Aspen Network event:
Revolving dates year-round, contact Meg Fields Psy.D, RN for upcoming opportunities: megfields.aspen@gmail.com, Ph: (925) 262-3135.

Where:
To be announced.

Online application submission PLUS a printed and signed copy:
Please fill out all sections of the following application form and supply all the requested information and materials. You will be able to electronically upload everything when you click the “Submit Application” button near the bottom. If you can’t complete the form entirely in one sitting, simply click “Save & Continue Later,” also near the bottom, to temporarily save what you have entered.

Note that you must download the Medical and Mental Health PDF forms (within the form below) and give them to your appropriate health professionals, to be filled out, signed and sent directly back to Aspen Network (following the directions on the forms) as promptly as possible.

VERY IMPORTANT: After you have fully completed the form — but before you click the “Submit Application” button — you must first print out a complete copy of the form and physically sign and snail-mail it to Aspen Network. After you have printed that out you can click “Submit Application” to send the electronic application. Note that we must receive BOTH the electronically submitted application and the physically-signed hard copy.

Application to Aspen Team Camp

Participant
Name*
First Middle Initial Last
Nickname
Gender*
DOB*
Age*
Siblings?*
Email
Mobile Phone
Alternate Phone
Please upload a recent photo
Accepted file types: jpg, png, tif, Max. file size: 5 MB.
Interview Preference (required for admission)
- In-Person Consult
- Video Consult
Size for free Aspen Team Camp T-shirt*
- Sml
- Med
- Lrg
- X Lrg
Family
Father's Name*
First Last
Father's Address*
Street Address City State ZIP Code
Father's Email*
Father's Mobile Phone*
Father's Alternate Phone
Father's Occupation
Mother's Name*
First Last
Mother's Address*
Street Address City State ZIP Code
Mother's Email*
Mother's Mobile Phone*
Mother's Alternate Phone
Mother's Occupation
Parent Questionnaire
1. What are your young person's greatest strengths?*
2. What are your concerns?*
3. What strategies/interventions have worked best with your young person?*
4. To your knowledge, has your young person ever been aggressive, self-injurious, threatening or had suicidal ideation? If so, please describe circumstances and frequency. How recently did this occur? What have been your most effective interventions?*
5. What is the most important thing we should know about your young person?*
6. Do you feel your young person will succeed at the camp, and how would you define his or her success?*
7. Has he or she attended previous camps?*
8. Describe your young person’s swimming ability:*
9. Have there been any recent significant events or any hospitalizations?*
10. How does your young person interact with other young people?*
- With Ease
- Some Challenge
- With Difficulty
11. What situations are particularly challenging?*
12. What specific services does your young person receive at school?*
13. Does your young person see mental health professionals, and how often? Do you think it is helpful?*
14. Please list your young person’s current meds. Have there been any recent changes?*
Participant Questionnaire
1. Have you had a previous camp experience that you enjoyed?*
2. What are you looking forward to? (list up to 3 things)*
3. Are there any things you are NOT looking forward to? (list up to 3 things)*
4. What makes you feel good? What do you appreciate?*
5. What stresses you out or makes you angry?*
6. What do you find scary or just not like to do?*
7. What are you best at? What do you love?*
Participant Agreement
I AGREE:

• To respect all members of our community, their property and the natural environment.

• To try my best.

• To ask for what I need to be successful.

• To share learning experiences, learning how to teach and explore my ideas with others.

• To take my share of responsibility. (There are some chores.)

• To communicate with the leaders and peers.

• To uphold our safety and kindness policy, understanding that the Aspen Team will support me and listen to what I need and what I have to say, but that there is zero tolerance for any mean or aggressive behavior towards myself or others.

• To have fun and enjoy myself and others, respecting my own unique expressions and learning more about enjoying others.

• To contribute my suggestions and be part of the development of new possibilities and experiences.

By my signature at the bottom of this form I agree to these expectations.
Medical Health History Form – to Download
Please click below to download the Medical Health History Form. Give it to your physician — requesting them to complete and return it directly back to Aspen Network as soon as possible, per the specific directions on the form.

Download Medical Health History Form
Mental Health Form – to Download
Please click below to download the Mental Health Form. Give it to your mental health professional — requesting them to complete and return it directly back to Aspen Network as soon as possible, per the specific directions on the form.

Download Mental Health Form
Terms and Conditions
1. All participants will agree to follow Aspen Team Camp rules regarding safety, respect for self and others, care for Aspen Team Camp living spaces and equipment, and care for the natural environment. Illegal drugs, alcohol or weapons are forbidden at Aspen Team Camp.
2. Cost of Aspen Team Camp is subject to change. Cost for upcoming Camp is shown on the aspennetwork.net website on the Camp Application page. The stated initial deposit is due at enrollment. The full balance is due by May 31st of the Camp year.
3. As staff, we do our best to select young people who will be successful at Aspen Team Camp. In the rare event that a young person is consistently unable to follow rules or is likely to do harm to him / herself or others, we reserve the right to dismiss the child. We will first discuss, work with, and try to adapt the environment for the young person before this step is taken. Under these circumstances, no refunds will be made.
4. Medical care: Nursing care provided by Aspen Team Camp health care staff is included in the tuition. Parent grants Aspen Team Camp permission to utilize medical treatment (including Emergency Room visit, dental, orthodontia or optical) outside of Aspen Team Camp should the camp director(s) deem such treatment necessary for participant’s well being. In these cases, all expenses involved will be paid by parent.
5. Parent must inform the Director prior to registration if the youth has received professional counseling or medication or a behavioral modification program during the last 12 months. Parents must also inform the Director immediately if such care or medication occurs after registration and prior to the camp session.
6. Late Arrival / Early Departure: Please make every effort to be sure that the child joins us on the opening day and can stay through the last day.
7. Parent grants participants permission to participate in all Aspen Team Camp activities, excursions and special outings. We will make every effort to insure the safety of the youth whether at Aspen Team Camp or when participating in water sports, hiking, backpacking, or other activities. Parents must understand that while unlikely, accidents, injuries or death may occur in the natural course of such activities.
8. Permission is hereby given for Aspen Team Camp to use in promoting the Camp and in other ventures directly relating to Aspen Team Camp (i) digital, photographic, video, and audio images or likenesses of youth; and (ii) statements, articles, names, art, photographs, audio recordings, films and videos created by the participant or originating from Aspen Team Camp or from a Aspen Team related activity.
9. Aspen Team Camp is not responsible for young people’s belongings or equipment while in transit or at Aspen Team Camp.
10. All claims or disputes by children or parents against Aspen Team Camp and arising from or related to this agreement will be brought to the courts of the state of California (Nevada County) and parent expressly submits to the jurisdiction of such courts. The substantive law of the State of California will govern such disputes without regard to conflict of law rules. Any individual bringing legal action against Aspen Team Camp, which action is decided in favor of Aspen Team Camp will be responsible for all legal fees, court costs, and out-of-pocket expenses of Aspen Team Camp, its owners and employees.
I/we have carefully read the above Terms and Conditions agreement, and by checking this box and by my/our signature(s) at the bottom of this application form I/we agree to its terms.*
- I have read the above Terms and Conditions
Participant Release of Liability and Assumption of Risk Agreement
I/we permit my/our young person to attend and participate in the entire Aspen Team Camp this year. Aspen Team Camp will be providing education/guiding services. I/we have read and understand the entire retreat description. While I/we understand that Aspen Team Camp is providing supervision of this camp, I/we acknowledge the disclosures and disclaimers contained in the information provided for this camp, including the following: The camp involves travel, rock climbing, yoga exercises, hiking in mountainous terrain, water activities and boating; Aspen Team Camp is not responsible for my/our young person’s equipment; and Aspen Team Camp will not be providing 24 hour per day supervision of the youth participants, but all planned outdoor activities will be adult-supervised. There will always be supervisory staff available. I/we also understand that there are inherent risks of serious personal injury and possibly death or paralysis, or property damage involved in all of the above activities and travel, and that it is not practicable for Aspen Team Camp to provide supervision of such activities at all times. I/we voluntarily assume and accept such risks of personal injury and property damage arising from my/our young person’s attendance and participation in such activities and travel.
I/we release, indemnify, and hold harmless Aspen Team Camp, its owners, officers, employees and agents from all actions, claims or demands that I/we, my/our young person, our heirs or representatives now have or may have in the future for personal injuries or property damage resulting from my/our young person’s attendance and / or participation. I/we agree that this release includes personal injury and / or property damages caused by negligence, active or passive, of Aspen Team Camp and its owners, officers, employees and agents; however, the release does not apply to liability for gross negligence, willful injury, fraud or intentional violation of law. This release is not intended to release Aspen Team Camp’s insurer or non-agent third parties of any responsibility for any claims that may be asserted, including those risks expressly released herein. The provisions of this agreement shall remain in effect throughout the completion of the retreat.
Occasionally Aspen Team Camp will use photos and/or video shot during our educational programs for inclusion with our education program promotional materials such as newsletters, or web sites, slide shows etc. By signing this agreement you are giving us permission to use such images without additional approval and without restriction.
I/we have carefully read the above Release of Liability and Assumption of Risk agreement, and by checking this box and by my/our signature(s) at the bottom of this application form I/we agree to its terms.*
- I have read the above agreement
Permission to Treat and Medication Authorization
PERMISSION TO TREAT
In the event I cannot be reached in an emergency, by my signature at the bottom of this form I give permission to the medical personnel selected by the Aspen Team Camp director to provide routine health care; to administer medications; 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. I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for my child, the Aspen program participant named at the top of this form.
MEDICATION AUTHORIZATION
By my signature at the bottom of this application form I authorize Aspen Team Camp personnel to administer the medication(s) specified below to my child. I understand that prescription medications shall be in the original container and labeled with the child’s name and instruction, including times and amounts for dosages, and the physician’s name. All non-prescription medication shall be in the original container and labeled by the parents with their child’s name and instructions for administration, including times and amounts for dosages.
I authorize Camp personnel to administer the following prescription medication(s) to my child. Please specify medication, dosage and times for each and any RECENT CHANGES in medications. (If none, state "None.")*
Over-the-counter medications
I also give permission for Aspen Team Camp to administer the following over-the-counter medications if the staff deems it necessary. Dosages will be administered according to directions on the bottle: Tylenol, Advil, Aspirin, Maalox, Imodium AD, Calamine Lotion, Benadryl, cold medicines, treatment for sore throat, and insect bite ointments.
I/we have carefully read the above Permission to Treat and Medication Authorization agreement, and by checking this box and by my/our signature(s) at the bottom of this application form I/we agree to its terms.*
- I have read the above agreement
Your Insurance Information
Please scan and upload Insurance Card – FRONT SIDE*
Accepted file types: jpg, png, tif, pdf, Max. file size: 5 MB.
Please scan and upload Insurance Card – BACK SIDE*
Accepted file types: jpg, png, tif, pdf, Max. file size: 5 MB.
Application Approval Signatures
Aspen Network requests that you provide both an e-signature and a hard copy signature. However, if you prefer to do only a hard-copy signature, please indicate that by checking this box.*
- I prefer to submit a hard-copy signature only
By our signatures below we affirm:

1. That the above information is true and complete to the best of our knowledge.

2. That we have carefully and completely read and accept the Terms and Conditions, Participant Release of Liability and Assumption of Risk as stated in the above sections.

3. That we understand and grant our permissions for the Permission to Treat and Medications Authorization as stated in the above sections.

4. That we have downloaded the Medical and Mental Health Forms and will provide those to our appropriate health professionals with instructions to complete and return them directly to Aspen Network ASAP.
Parent/Guardian Name*
Parent/Guardian E-Signature ("/s/name")
Parent/Guardian Hand-written Signature
Date
Parent/Guardian Name
Parent/Guardian E-Signature ("/s/name")
Parent/Guardian Hand-written Signature
Date
Applicant/Participant Name*
Applicant Participant E-Signature ("/s/name")
Applicant/Participant Hand-written Signature
Date
PRINT OUT your completed application – BEFORE submitting - But PLEASE hit SUBMIT BELOW so that we get the electronic copy.
Very Important: BEFORE clicking the Submit button below you must FIRST click the PRINT THIS APPLICATION button at the very bottom to print out a copy of your completely filled-out application.*
- Yes, I have printed out a hard copy of my filled-out application
Submit Completed Application
Comments
This field is for validation purposes and should be left unchanged.

Save and Continue Later

IMPORTANT: BEFORE clicking the Submit button above, you must FIRST click the Print This Application button below to print out your completed application.

CAMP APPLICATION CHECKLIST

In addition to the electronic version of the application (sent when you clicked the Submit Application button above) the following items must also be sent to Aspen Network:

1. Please snail-mail a printed copy of the fully completed application — with all required hand-written signatures. (Please also keep a copy of this document for your own records.)

2. With the above, please include your initial program deposit of $1000.00 — in check or money order payable to Aspen Network.

3. Please remember to download the Medical and Mental Health PDF forms (from the application above) and give those to your appropriate health professionals. They will need to fill out and return those directly to us ASAP, please.

Please send all of the above materials to Aspen Network:

Aspen Network
Attn: Meg Fields, RN, Psy.D.
15 Vallecito Lane
Orinda, CA 94563
Email: info@AspenNetwork.net

Application for Aspen Network Events

Application to Aspen Team Camp

Participant

Family

Parent Questionnaire

Participant Questionnaire

Participant Agreement

Medical Health History Form – to Download

Mental Health Form – to Download

Terms and Conditions

Participant Release of Liability and Assumption of Risk Agreement

Permission to Treat and Medication Authorization

Your Insurance Information

Application Approval Signatures

PRINT OUT your completed application – BEFORE submitting - But PLEASE hit SUBMIT BELOW so that we get the electronic copy.

Submit Completed Application