Applications are due May 15, 2017. In addition to this form, please send your completed Camper Health History Form (PDF) to Elyse Voyen at:
Elyse Voyen, firstname.lastname@example.org | Via mail: Greenheart International c/o Elyse Voyen, 712 N. Wells St. Floor 2 Chicago, IL 60654
Complete el Formulario de Registro y Beca de Camper (PDF) y el Formulario de Historia de Salud de Camper (PDF) y entrega a:
Correo Electronico: Elyse Voyen, email@example.com | o por correo: Greenheart International c/o Elyse Voyen, 712 N. Wells St. Floor 2 Chicago, IL 60654
Please provide a teacher or coach who can speak to your child’s interests and behavior. We will be contacting this individual and their comments will be considered in determining you child’s scholarship acceptance.
Please have your child write 2-3 sentences about why they want to attend Camp Greenheart.
Camp Greenheart Scholarship’s income guidelines are based on the United States Department of Agriculture's guidelines for reduced price meals. We will accept applications from families earning up to $20,000 per year over the USDA guidelines. The size of a family's household should be calculated including children. Below are the income rates we use to determine eligibility (the amount already displays $20,000 over the USDA guideline).
Space is limited; we can only accept 50 scholarship recipients who meet these guidelines. Families that earn more per year than the amounts listed about the guidelines are not eligible for a scholarship.
List every member of your household, including children, as well as their gross income and how often it was received.
Example: $100/monthly, $100/twice a month, ect.
I certify that all information on this form is true and that all income is reported. I understand that if I purposely give false information, the participant receiving assistance may lose the scholarship and I may be prosecuted.
THIS SECTION MUST BE SIGNED BY PARENT AND/OR GUARDIAN BEFORE REGISTRATION IS ACCEPTED.
I hereby give permission to Greenheart International to transport the child named above off the camp property for the purpose of medical care or program activities as deemed appropriate by the Camp Director. I hereby authorize the camp RN to provide for and secure treatment of all health issues that arise at camp for child named above. In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthetic or surgery for the child named above.
I understand that Greenheart International does not provide accident/medical insurance for the child named above. Medical bills, including prescription drugs, will be the responsibility of the parent or guardian named below. If applicable, I authorize Greenheart International to use my credit cards on file to pay for medical bills and/or prescription drugs. Rules for campers are the same for everyone without regard to race, color, national origin, gender or disability. I understand that all campers will be treated as individuals and respect will be shown for a range of abilities and behaviors. I agree that Greenheart International reserves the right to dismiss a child from camp whose special needs they are not able to provide for or whose conduct is not in the best interest of the camp community, without refund. I will notify the director if my child has any serious restrictions related to his/her participation in the camp program. Greenheart International has my permission to use photographs and/or video taken of my child while at camp for promotional purposes.
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Greenheart International, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to:
a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice
b) Permission to use my name
c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproductions(s) of me, and/or recording of my voice, in part of in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for education and awareness.
The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.
712 N Wells 4th Floor,
Chicago, IL 60654, USA
Toll-Free in the U.S: 866-224-0061