Camper's Information

Parent/Guardian Information

Emergency Contact Information

Health & Medical Information

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Break The Cycle Today’s Summer Camp will not administer any prescription medications during the course of the program.

We ask that families make arrangements for any required medications to be administered before or after camp hours. If your child must take medication during the camp day, they must be able to self-administer the medication independently. Camp staff are not permitted to administer or supervise the administration of any prescription medications.

The only exceptions to this policy are the following over-the-counter and emergency-use products, which may be administered with appropriate documentation and parental consent:

• Topical ointments, creams, lotions, and sprays (including sunscreen and insect repellent)

• Emergency epinephrine auto-injectors (EpiPens)

• Diphenhydramine in combination with an epinephrine auto-injector

• Asthma inhalers

• Nebulizers

By signing below, I acknowledge and understand that:

• The camp staff will not administer any prescription medications to my child.

• If my child requires medication during the camp day, they must be capable of self-administration.

• I am responsible for ensuring all emergency-use medications and topicals are provided with proper authorization if applicable.

To attend camp, all participants must have an updated physical exam form completed and signed by a licensed medical provider. This form must:

• Be dated within 12 months of the camp start date

• Include documentation of all required immunizations

• Be submitted before the first day of camp

Campers will not be allowed to participate in physical activity until this form is received and reviewed by the camp administration.

By signing below, I agree to:

• Submit my child’s most recent physical exam form by the camp start date, July 28th, 2025.

• Understand that failure to meet these requirements may result in my child being unable to participate in camp activities.

Transportation & Dismissal

Camp Session Selection

Financial Assistance Application:

Only complete this section if you wish to apply for financial assistance. All information is confidential.

Break The Cycle Today is committed to ensuring that all families have access to our summer camp experience, regardless of financial circumstances. Limited financial assistance is available and awarded based on demonstrated need and available funding.

By applying for financial assistance, you acknowledge and agree to the following:

• You will be required to submit supporting documentation (e.g., proof of income, recent pay stubs, or government assistance letters) for our internal review process.

• Your application for financial assistance does not guarantee a reduction in tuition. Awards are granted based on need and the availability of scholarship funds.

• All information submitted will be kept confidential and used solely for the purpose of assessing financial assistance eligibility.

• If your application is approved, you will receive a notification via email outlining the amount of tuition reduction (if any) and the adjusted balance due.

• You are responsible for submitting all required documents in a timely manner. Incomplete or late submissions may result in delayed or denied assistance.

Consent & Agreements

Please read the following terms and conditions carefully. By signing below, you agree to the policies and waivers listed and give your full consent for your child’s participation in Break The Cycle Today’s Summer Camp.

I hereby give permission for my child to attend and participate in all activities and programs offered by Break The Cycle Today Summer Camp. I understand that participation in camp activities is voluntary and may involve physical activity and outdoor experiences.

I understand that while every effort is made to provide a safe environment, participation in camp activities carries a risk of injury. I acknowledge and agree that Break The Cycle Today, its staff, volunteers, partners, and affiliates are not liable for any injuries, accidents, or damages that may occur to my child during camp, including but not limited to travel to and from the program or any field trips. I voluntarily assume all risks related to my child’s participation.

In the event of a medical emergency, I authorize the camp staff to seek appropriate emergency medical care for my child. I understand that camp staff are not permitted to administer prescription medications and agree to abide by the camp’s Medication Policy.

I agree to provide an updated physical form from my child’s healthcare provider by the start of camp. I understand that failure to provide this form may prevent my child from attending camp.

I give permission to Break The Cycle Today to photograph, film, or record my child during camp activities. I understand that these photos and videos may be used for educational, promotional, or fundraising purposes, including social media, printed materials, and the organization’s website. I waive any right to compensation or ownership of such media.

I understand that if my child displays inappropriate or unsafe behavior that disrupts the camp environment or places others at risk, Break The Cycle Today reserves the right to dismiss my child from the program. I acknowledge that no refunds will be issued in such cases.

By signing below, I confirm that I have read and understood all policies outlined in this application, including the Medication Policy, Physical Form Requirement, and Consent & Waivers. I agree to follow all camp procedures and support my child’s participation in a safe and respectful manner.