Camp CARE 2023

Name: Camp CARE 2023
Start: 2023-07-17T09:00:00-04:00
End: 2023-07-28T15:00:00-04:00
Location: Fountain Elementary

Details

Start:

July 17 @ 9:00 am

End:

July 28 @ 3:00 pm

Venue

Fountain Elementary

16850 Wellington Ave
Roseville, MI 48066  United States + Google Map

PRESCHOOL – HIGH SCHOOL | July 17-28 (Monday-Friday) | 9 AM-3 PM | Cost: Free
Fountain Elementary 16850 Wellington Ave., Roseville, MI 48066

Does your child worry about a loved one’s struggles with alcohol, opioids, or other drugs? Are you an individual in recovery who has children in your life? Would your child benefit from skills to address worries related to their loved one’s substance use and addiction?

Camp CARE is a two-week camp for children in preschool through 8th grade from July 17-28 (Monday-Friday) at Fountain Elementary in Roseville from 9am-3pm. Boxed lunches will be provided.

CHILDREN WILL LEARN SKILLS TO:
Communicate Effectively • Manage Emotions & Self-Control • Deal Effectively with Change
Choose Friends Wisely • Make Healthy Choices • Resist Peer Pressure

For any questions, contact Erika Bradbury, Prevention Program Manager at ebradbury@careofsem.com

Camp CARE 2023

Step 1 of 6

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CAMP CARE Summer Registration 2023
July 17-28 (Monday-Friday) from 9:00 am to 3:00 pm at Fountain Elementary School - 16850 Wellington Ave, Roseville, MI 48066. Please complete all information on the registration form. All information provided to CARE is strictly confidential.
Parent/Caregiver Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
May we send mail to your address?*
May we send email to your email address?*
May we call the phone number provided?*
May we leave a voicemail at the phone number provided?*
Has your child/children participated in the CARE Summer Program before?*
How did you hear about our program (where advertised)?*

Family Stressors
Has your family been impacted by Covid-19?*
Has your family moved in the last year?*
Has child experienced a recent death of family or friend?*
Has there been a divorce/separation in the family?*
Has there been a remarriage in the family?*
Any other issues your family has been impacted by?*
What other issues has your family been impacted by?
If you answered 'YES' to the previous question.

Alcohol & Other Drug Use Concerns
This section is to identify how the children have been impacted by substance use.
Name of family member/loved one who has an alcohol or other drug use concern
First Last
Relationship to child
Is he/she in recovery?
Is he/she currently in treatment?
Is the child aware of the family member/loved one's substance use?
Name of family member/loved one who has an alcohol or other drug use concern
First Last
Relationship to child
Is he/she in recovery?
Is he/she currently in treatment?
Is the child aware of the family member/loved one's addiction?

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Age*
School Attending*
School District*
Who does the child live with?*
Does your child have difficulty making/keeping friends?*
Does your child have difficulty managing anger?*
Does your child have trouble staying focused?*
Are there any learning disabilities or mental health issues?*
Please list any disabilities or mental health issues?*
Put N/A if does not apply
Is your child attending counseling/support groups?*
List all allergies (food, medication and animals)*
Put N/A if does not apply
Does your child take any medications regularly?*
- Yes
- No
Reason for medication:*
Put N/A if does not apply
List all current medications and dosage*
Put N/A if does not apply
List all medications your child may need to take at camp:*
Put N/A if does not apply
**Medication should be turned in to camp supervisor upon registration the first morning of camp. Please bring emergency medications such as epi pen, inhaler, etc. to camp along with a printed copy of the medical treatment Action Plan. Campers may not attend camp without their medication on site.
Does your child have any medical conditions listed below?
Seizures*
- Yes
- No
Diabetes*
- Yes
- No
Asthma*
- Yes
- No
Other (please describe):
Tell us about a few of your child’s strengths and positive qualities:*
Name
First Last
Date of Birth
MM slash DD slash YYYY
Age
School Attending
School District
Who does the child live with?
Does your child have difficulty making/keeping friends?
Does your child have difficulty managing anger?
Does your child have trouble staying focused?
Are there any learning disabilities or mental health issues?
Please list any disabilities or mental health issues?
Put N/A if does not apply
Is your child attending counseling/support groups?
List all allergies (food, medication and animals)
Put N/A if does not apply
Does your child take any medications regularly?
- Yes
- No
Reason for medication:
Put N/A if does not apply
List all current medications and dosage:
Put N/A if does not apply
List all medications your child may need to take at camp:
Put N/A if does not apply
**Medication should be turned in to camp supervisor upon registration the first morning of camp. Please bring emergency medications such as epi pen, inhaler, etc. to camp along with a printed copy of the medical treatment Action Plan. Campers may not attend camp without their medication on site.
Does your child have any medical conditions listed below?
Seizures*
- Yes
- No
Diabetes*
- Yes
- No
Asthma*
- Yes
- No
Other (please describe):
Tell us about a few of your child’s strengths and positive qualities:
Name
First Last
Date of Birth
MM slash DD slash YYYY
Age
School Attending
School District
Who does the child live with?
Does your child have difficulty making/keeping friends?
Does your child have difficulty managing anger?
Does your child have trouble staying focused?
Are there any learning disabilities or mental health issues?
Please list any disabilities or mental health issues?
Put N/A if does not apply
Is your child attending counseling/support groups?
List all allergies (food, medication and animals)
Put N/A if does not apply
Does your child take any medications regularly?
- Yes
- No
Reason for medication:
Put N/A if does not apply
List all current medications and dosage:
Put N/A if does not apply
List all medications your child may need to take at camp:
Put N/A if does not apply
**Medication should be turned in to camp supervisor upon registration the first morning of camp. Please bring emergency medications such as epi pen, inhaler, etc. to camp along with a printed copy of the medical treatment Action Plan. Campers may not attend camp without their medication on site.
Does your child have any medical conditions listed below?
Seizures*
- Yes
- No
Diabetes*
- Yes
- No
Asthma*
- Yes
- No
Other (please describe):
Tell us about a few of your child’s strengths and positive qualities:

Emergency Contacts
Please list two (2) contacts in case of emergency
Name*
First Last
Phone*
Relationship to child*
Name*
First Last
Phone*
Relationship to child*
Pick Up Permissions
List anyone who may be picking up your child/children other than yourself
Name
First Last
Phone
Relationship to child
Name
First Last
Phone
Relationship to child

Social Media and Photo Consent
Social Media Release*
Parent/Guardian, select 'YES' if you grant CARE of Southeastern Michigan the absolute and irrevocable right and unrestricted permission concerning the use of photographs that may be taken which may include with others, to use, reuse, publish, the photographs in whole or in part, individually or in connection with other materials. I release and discharge photographer from any and all claims that may arise out of or in connection with the use of the photographs, including without limitation any and all claims for liable or violation of any right of publicity or privacy.
Participating Consent
By typing your name below you, give permission for your child/children to participate in the CARE Youth Support Camp Program. I understand the significance and importance of this program and I will take an active role in this experience and will support my child’s understanding of the concepts and ideas it presents. I also understand that if the site director suspects that the person designated to pick up my child is under the influence or intoxicated, that an alternative ride home will be identified.
Parent/Guardian Signature*
Today's Date*
MM slash DD slash YYYY

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Venue

Fountain Elementary

16850 Wellington Ave
Roseville, MI 48066  United States + Google Map

Camp CARE 2023

Details

Venue

Camp CARE 2023

Step 1 of 6

CAMP CARE Summer Registration 2023

Family Stressors

Alcohol & Other Drug Use Concerns

**Medication should be turned in to camp supervisor upon registration the first morning of camp. Please bring emergency medications such as epi pen, inhaler, etc. to camp along with a printed copy of the medical treatment Action Plan. Campers may not attend camp without their medication on site.

Does your child have any medical conditions listed below?

**Medication should be turned in to camp supervisor upon registration the first morning of camp. Please bring emergency medications such as epi pen, inhaler, etc. to camp along with a printed copy of the medical treatment Action Plan. Campers may not attend camp without their medication on site.

Does your child have any medical conditions listed below?

**Medication should be turned in to camp supervisor upon registration the first morning of camp. Please bring emergency medications such as epi pen, inhaler, etc. to camp along with a printed copy of the medical treatment Action Plan. Campers may not attend camp without their medication on site.

Does your child have any medical conditions listed below?

Emergency Contacts

Pick Up Permissions

Social Media and Photo Consent

Participating Consent

Venue