For emergency assistance please call UNC's Community Service Department at 570.343.8835

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Project Hope Day Camp Registration

Notification to Community

UNC - Project Hope

Step 1 of 2

50%

Basic Camper Information
Camper Name*
First Last
Has Camper completed Kindergarten?*
- Yes
- No
Will the child be younger than 6 by September 1, 2024?*
- Yes
- No
Will the child be 15 by September 1, 2024*
- Yes
- No
Camper is not able to attend camp.

Birth Date*
MM slash DD slash YYYY
Gender Identity*
- Female
- Male
- Other
Race*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
- Other
Please Specify
Ethnicity*
- Hispanic/Latino
- Not Hispanic/Latino
Is the Camper a foster child?*
- Yes
- No
Was the Camper referred through Lackawanna County’s Office of Youth and Family Services (OYFS)?*
- Yes
- No
Primary Language*
Please Specify
School*
School - Other
Street Address*
Street Address Address Line 2 City State ZIP Code
County*
Upload Photo
Max. file size: 34 MB.
Camper Care Information
Does the camper have an IEP (Individualized Education Plan) or do they receive any assistance/special support from school?*
- Yes
- No
Upload Document
Max. file size: 34 MB.
Will the camper have a Behavioral Health Technician (BHT, formerly TSS) or other support staff with them onsite?*
- Yes
- No
Please identify the agency, name, and contact information for the child’s case.
Can the camper swim?*
Food Restrictions*
- Lactose
- Gluten
- Pork
- Vegan
- Vegetarian
- None
- Other
Please Explain
Allergies
- Has Allergies
- None
Allergies (List any allergy and reaction)
Medications at Camp*
*Note: Medications must come to camp in their original bottle, be prescribed to the camper, and be given exactly as prescribed.
Medication Name
Medication Dosage
Reason for Medication
Medication Instructions
Medication Name
Medication Dosage
Reason for Medication
Medication Instructions
Medication Name
Medication Dosage
Reason for Medication
Medication Instructions
Preferred Bus Stop Location
Preferred Bus Stop Location*
Medical History and Coverage
Health Insurance Company*
Health Insurance Holder*
Health Insurance Number*
Has the camper ever been hospitalized or had surgery?*
- Yes
- No
Does the camper have a recent, recurring, or chronic illness, injury, or infectious disease?*
- Yes
- No
Does the camper have breathing complications like asthma, wheezing, or chronic shortness of breath?*
- Yes
- No
Does the camper experience dizziness or fainting, or have they had seizures?*
- Yes
- No
Does the camper have trouble falling asleep and do they experience sleepwalking?*
- Yes
- No
Has the camper ever had back, joint, or skin problems?*
- Yes
- No
Does the camper have diabetes?*
- Yes
- No
Has the camper traveled outside the country since December 2023?*
- Yes
- No
Has the camper ever been treated for ADD, ADHD, emotional or behavioral difficulties, or an eating disorder?*
- Yes
- No
During the past 12 months, has the camper experienced mental and emotional health concerns and/or had a significant life event that continues to cause them distress?*
- Yes
- No
Is there anything else we need to know about your camper in order to ensure they are safe and healthy in our care?*
- Yes
- No
If Yes to any of the Yes/No questions above, please explain dates, details, and special care requests.
Household Information
Number of children (0-12) in the household*
Number of teens (13-17) in the household*
Number of adults (18+) in the household*
Does the head of household identify as a single parent?*
- Yes
- No
Total household income*
Pay Frequency*
If any household members currently participate in SNAP (food stamps), TANF, or FDPIR, please enter your case number. (This number begins with 35, 40 or 64, depending on your County of Residence.)
If you filled this form out with the assistance of a case worker or UNC staff, please include their name
Guardian 1
Guardian 1 - Name*
First Last
Primary Language*
Please Specify
Phone 1*
Phone 2
Address*
Street Address Address Line 2 City State ZIP Code
Email*

*Note: Email will be our primary method of communication leading up to camp
Confirm Email*
Would you be interested in obtaining/learning more about technical training though a one-year educational program to enter a high-demand field?*
- Yes
- No
General Eligibility - RISE (risenepa.org)
Guardian 2
Guardian 2 - Name
Primary Language
Please Specify
Phone 1
Phone 2
Address
Street Address Address Line 2 City State ZIP Code
Email

*Note: Email will be our primary method of communication leading up to camp
Confirm Email
Would you be interested in obtaining/learning more about technical training though a one-year educational program to enter a high-demand field?
- Yes
- No
General Eligibility - RISE (risenepa.org)
Emergency Contact
(Must be different from Guardian 1)
Emergency Contact - Name*
First Last
Primary Language*
Please Specify
Relationship to Camper*
Phone 1*
Phone 2
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Confirm Email*
General Authorization and Release of Liability
The health history I provided is correct and accurately reflects the health status of the individual to whom it pertains. The camper has permission to participate in all camp activities except as noted here and/or by an examining licensed medical professional. I give permission to the licensed medical professional selected by camp and camp leadership staff to order treatment related to the health of the individual for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the licensed medical professional to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the individual. I understand the information on the registration form will be shared on a “need to know” basis with camp staff. I give permission to print and photocopy all forms and information. I give permission for camp staff to provide basic first aid as needed, as well as for the licensed medical professional to provide more in-depth medical care whenever necessary. In submitting this application, I hereby accept the care and direction of United Neighborhood Centers of NEPA’s (UNC) staff and hold the organization and its staff harmless from all liability claims and/or damages that may result from my child’s participation in camp, including the outdoor adventure-learning ropes course, rock wall, and zip line. I approve this application.
Camper Name*
First Last
Camper Birthdate*
MM slash DD slash YYYY
Camper Signature*
Guardian 1 - Name*
First Last
Guardian 1 - Signature*
Guardian 2 - Name*
First Last
Guardian 2 - Signature*
Photo Release
UNC has my permission to use any photographs or videos taken of my child for camp materials, media, and promotion
- UNC has my permission to use any photographs or videos taken of my child for camp materials, media, and promotion
UNC may not use photographs or videos
- UNC may not use photographs or videos
Guardian 1 - Name*
First Last
Guardian 1 - Signature*
Guardian 2 - Name
First Last
Guardian 2 - Signature
Outdoor Adventure Course Release of Liability
I understand that even under the safest conditions, the activities on the course have a number of inherent risks involving injury, disability, or even death. I understand that the major classes of hazards associated with this type of training include splinters or injuries resulting from falls or from contact with course apparatus. I recognize that course participation typically requires close physical contact by participants. I further understand that the activities on the Outdoor Adventure Course may be physically, mentally, and/or emotionally demanding. I verify that I am free of any mental, medical, and/or physical conditions that may create undue risk to myself or to others who depend on me. I agree to comply with all the safety rules and regulations set forth by the Outdoor Adventure Staff. I also agree to inform them of any condition or situation that may be dangerous to myself or my co-participants. I certify that I am at least 18 years of age or have obtained consent from my parent or legal guardian, as indicated by the signature and date below. In consideration of being permitted to participate in UNC’s Camp Kelly Outdoor Adventure program, I,
Camper Name*
First Last
, for myself, my heirs, successors and assigns, hereby indemnify, release and hold harmless UNC’s Camp Kelly, agents, officers, and/or employees and volunteers and United Neighborhood Centers of NEPA, its agents, officers, and/or employees and volunteers, from any and all claims, demands, causes of action or damages which may accrue on account of bodily or personal injury, property damage, or death suffered by myself, (my child), or any third parties, including employees of UNC’s Camp Kelly, arising from the negligence of the aforesaid parties. I, for myself, my heirs, successors and assigns, herby assume any and all risks attendant to my participation in UNC’s Camp Kelly Outdoor Adventure course.
Camper Name*
First Last
Camper Birthdate*
MM slash DD slash YYYY
Camper Signature*
Guardian 1 - Name*
First Last
Guardian 1 - Signature*
Guardian 2 - Name
First Last
Guardian 2 - Signature
Camper & Parent Conduct Agreement
At Camp Kelly, I will treat camp staff, fellow campers, and the facilities with care and respect. I will follow the direction of camp staff. If anyone or anything makes me feel unsafe or uncomfortable, I will talk with a trusted staff member. I understand that I play an important role in the enjoyment of every camper and staff member at Camp Kelly. I will treat everyone in my camp community with care, honesty, and respect. I understand that bullying in any form is unacceptable. If I am having trouble with this, or with the way others are treating me, I will talk to a Camp Kelly staff member immediately.

Camp Kelly is a place of retreat. I will not cloud up the atmosphere with swearing, offensive language, or social cruelty. I will not bring drugs, alcohol, vapes, lighters, or weapons onto camp property. I will not bring any medication (over the counter, supplemental, or prescription) to camp – if I need medication onsite, it will be given to the bus counselor and stored safely in the Infirmary.

I understand that my actions and words are my own and I get to choose how to behave. If my actions or words cause others to feel unsafe or unwelcome and I am unwilling to change my behaviors or my words, I understand that I may be dismissed from Camp.

I look forward to joining the Camp Kelly community (if I am new) or welcoming others to Camp Kelly (if I am returning). I will bring my best self to camp and will work with those around me to ensure everyone has a great summer.
Camper Name*
First Last
Camper Signature*
Guardian 1 - Name*
First Last
Guardian 1 - Signature*
Guardian 2 - Name
First Last
Guardian 2 - Signature
Payment*
- Pay $5 deposit
- I have paid the $5 deposit on another camper from my household or have paid the $5 deposit to the UNC staff listed in my application. I understand my application will be considered incomplete and invalid if I have not paid a $5 fee for my family.
- I cannot pay the $5 deposit and have been approved by a caseworker to continue the application without payment. I understand my application will be considered incomplete and invalid until my caseworker requests a fee waiver on my behalf.
Total
$0.00
Credit Card*
Card Details
Cardholder Name

About

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News & Events

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Volunteer

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Contact

United Neighborhood Centers of
Northeastern Pennsylvania

425 Alder Street

Scranton, PA 18505

Phone: 570.346.0759

Fax: 570.207.4242

As a non-profit 501(c)(3) organization, donations to UNC are tax-exempt, and UNC complies with all 501(c)(3) rules and regulations.

If your are seeking emergency assistance for rent, housing, food, or utilities, please call UNC's Community Service Department at 570.343.8835

Project Hope Day Camp Registration

UNC - Project Hope

Step 1 of 2

Basic Camper Information

Camper Care Information

Preferred Bus Stop Location

Medical History and Coverage

Household Information

Guardian 1

Guardian 2

Emergency Contact

General Authorization and Release of Liability

Photo Release

Outdoor Adventure Course Release of Liability

Camper & Parent Conduct Agreement