Camper Registration - Chakra Pride

Camp Registration

We require a bit more information from you for the camp.
Please fill out the form below and submit it.

How did you hear about us? *

Are you applying for a scholarship or reciprocity model *

At Camp Heroes, we believe in the power of community and the spirit of giving, ensuring that our camp's adventures in learning, friendship, and growth are accessible to all young heroes, regardless of their financial background. Deadline for submission March 17

Choose the number of campers *

Number of campers this registration is for

Are these campers, siblings or live in the same household *

Parent/Gardiuan Account Details

Parent/ Gaurdian *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Preferred method of communication *

Call
Text
Email

Email *

Parent/Caregiver Photo *

Click or drag files to this area to upload. You can upload up to 4 files.

Do you wish to add a parent/gardian who resides at a different address? *

Additional Parent/Caregiver *

First

Last

Address of Additional Parent/Caregiver *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Preferred method of communication *

Call
Text
Email

Additional Parent/Caregiver Email *

Confirm Email

Additional Parent/Caregiver Photo *

Click or drag files to this area to upload. You can upload up to 4 files.

Emergency Contact Name *

First

Last

Emergency Contact Relationship *

Emergency Contact Phone *

Do you wish to add another Emergency Contact Name *

Additional Emergency Contact Name *

First

Last

Relationship *

Phone *

Camper's Information

Name *

First

Last

Date of Birth *

Pronouns *

Camper's Nickname

T-Shirt *

Gender *

Female
Male
Other

School *

Grade *

I certify this camper is potty trained. *

Camper's Doctor's Name *

First

Last

Phone *

Email *

Please let us know about any behavioral concerns: *

List N/A for none

Please let us know about any medical concerns: *

List N/A for none

Please let us know about any allergies (food, medication, environment): *

List N/A for none

Additional Camper Information

Name *

First

Last

Date of Birth *

Pronouns *

Camper's Nickname *

T-Shirt *

Gender *

Female
Male
Other

School *

Grade *

I certify this camper is potty trained. *

Is the doctor contact the same ? *

Doctor's Name *

First

Last

Phone *

Email *

Please let us know about any behavioral concerns: *

List N/A for none

Please let us know about any medical concerns: *

List N/A for none

Please let us know about any allergies (food, medication, environment): *

List N/A for none

Third Camper's Information

Name *

First

Last

Date of Birth *

Pronouns *

Camper's Nickname *

T-Shirt *

Gender *

Female
Male
Other

School *

Grade *

I certify this camper is potty trained. *

Is the doctor contact the same? *

Camper's Doctor's Name *

First

Last

Phone *

Email *

Please let us know about any behavioral concerns: *

List N/A for none

Please let us know about any medical concerns: *

List N/A for none

Please let us know about any allergies (food, medication, environment): *

List N/A for none

Fourth Camper's Information

Name *

First

Last

Date of Birth *

Pronouns *

Camper's Nickname *

T-Shirt *

Gender *

Female
Male
Other

School *

Grade *

I certify this camper is potty trained? *

Is the doctor contact the same. *

Camper's Doctor's Name *

First

Last

Phone *

Email *

Please let us know about any behavioral concerns: *

List N/A for none

Please let us know about any medical concerns: *

List N/A for none

Please let us know about any allergies (food, medication, environment): *

List N/A for none

Is anyone besides the listed Parent/Guardian allowed to pick up your camper(s)? *

Please list who can pick up your camper: *

Photos of those allowed to pick up your camper: *

Click or drag a file to this area to upload.

Scholarship & Reciprocity

At Camp Heroes, we believe in the power of camp to transform lives, foster growth, and create lasting memories. We also understand that financial constraints should not prevent any child from experiencing the joy and adventure of camp. Our scholarship program aims to support families who are passionate about their child's development but may face financial challenges. This application is designed with sensitivity and respect, ensuring a supportive process for every family.

Why Camp Heroes? *

Share with us why your child is drawn to Camp Heroes. What aspects of the camp experience do they find most exciting?

The Impact of Camp *

How do you believe attending Camp Heroes could benefit your child? Think about both personal growth and the joy of the camp experience.

Understanding Your Needs

Supporting Your Journey: *

We recognize that families come from diverse financial backgrounds. Without sharing specific numbers, could you let us know how a scholarship could support your family's situation?

Community Contribution: *

Camp Heroes is more than just a camp; it's a community. Are there ways you or your child might like to give back or contribute to the Camp Heroes community? This can be anything from sharing a skill to participating in community events.

Please help us understand your contribution level by selecting the option that best matches your family's financial situation: *

Heroic Supporter: I can cover the full camp fee, helping Camp Heroes extend its magic to more families in need of financial support.
Guardian Contributor: I am able to contribute about 75% of the camp fee, supporting my child's participation and contributing to the camp's community spirit.
Companion Level: I'm able to contribute about 50% of the camp fee, finding a balance that supports both my family and the Camp Heroes mission.
Helper Level: I can afford to contribute around 25% of the camp fee, needing significant support for my child's camp experience.
Hero Level: My family needs full support this time, and I am applying for a scholarship for my child to attend Camp Heroes at no cost.

Your Heart, Our Camp: A Union of Heroes

Your openness in selecting a contribution level enables us to make Camp Heroes accessible to every child, fostering an environment of inclusivity and support. If there are changes in your financial situation, or if you wish to discuss alternative support options, our doors and hearts are always open for conversation. By embracing this model, we can all contribute to a community where every child has the opportunity to thrive, learn, and create unforgettable memories at Camp Heroes.

Is there anything else you'd like us to know about your child or your family that could help us understand your application better?

Commitment to Confidentiality:

We respect your privacy and assure you that all information provided will be treated with the utmost confidentiality and sensitivity. This application is a safe space to share your story and how we can help make the Camp Heroes dream a reality for your child.

Signature *

Clear Signature

I affirm that the information provided is accurate and complete to the best of my knowledge and understand that it will be used solely for the purpose of evaluating this scholarship application.

Date / Time *

Date

Time

Camp Registration

Parent/Gardiuan Account Details

Camper's Information

Additional Camper Information

Third Camper's Information

Fourth Camper's Information

Scholarship & Reciprocity

Understanding Your Needs

Your Heart, Our Camp: A Union of Heroes

Commitment to Confidentiality:

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