APPLICATION PROCESS These Requirements Must Be Met in Order to Accept Your Application

2017 CAMP “DIVAS” with C.H.O.I.C.E.S. Week #1: June 5th – 9th or week #2: June 12th – 16th

CHILD Name: APPLICATION PROCESS These requirements must be met in order to accept your application.

Part 1. Determine if your child is in the 80th percentile. Calculate your child’s BMI using the CDC Table for Calculated Body Mass Index Values for Selected Heights and Weights for Ages 2 to 20 Years. (pdf) www.cdc.gov Go to http://www.cdc.gov/nccdphp/dnpa/bmi/00binaries/bmi-tables.pdf

Write Calculation Results: (BMI: ______) or ( PERCENTILE: ______)

Part 2. Determine if your child would benefit from the Camp. Please circle.  Child's age is between 10 – 17 ( Yes or No )

 Willing to learn by being physically active in groups ( Yes or No )

 Willing to learn by cooking healthy foods for lunch ( Yes or No )

Part 3. Complete Page 2. Pay the deposit of $25.00 or the full $150.00 Fee online at www.ChoicesForKids.org. Look for the Blue “Donate” on the right hand side of the home page. Then “Enter as a Guest”. Write your campers name in the notes section.

Applications are due by Friday, May 26, 2017 for the June 5 – June 9, 2017 Camp session. And, by Friday, June 2, 2017 for the June 12 – June 16, 2017 Camp session.

SUBMIT BY MAIL: 1275 Shiloh Road, Suite 2660, Kennesaw, GA 30144 SUBMIT BY FAX: 770.850.1236 SUBMIT BY EMAIL: [email protected]

Once a completed application and deposit is received, we will provide additional Camp Diva 2017 program specifics. If you have any questions call, 678.819.3663.

Part 4. If scholarship assistance is being requested, attach an essay of at least 250 words answering this statement: “I would like to participate in Camp Divas because”

Early application submission and deposit is strongly encouraged. All scholarship requests will be reviewed and decided by a committee. Notification of scholarship award amounts will be made continuously.

Page 2 2017 CAMP “DIVAS” APPLICATION (All form fields are required)

Child’s Child’s Name: Age: Address: Child’s Cell:

City: State Zip Code: Parent’s Name:

Parent’s Parent’s Email: Tel#:

Please provide the email address and cell phone number for the camper if they have one:

Short Medical History: (We may require additional information based upon responses) Are there any Allergies that we should be aware of?:

Are there any other medical conditions that we should be aware of?:

Has the Child had a Physical Exam within the last year?:

Please provide an emergency contact if parent or guardian cannot be reached: Emergency Contact name:

Emergency Contact phone number:

AS A PARENT OR GUARDIAN, I ASSUME ALL RISKS AND HAZARDS INCIDENTAL TO THE CONDUCT OF THE ACTIVITIES AND TRANSPORTATION TO AND FROM THE ACTIVITIES. I further hereby release, absolve, indemnify and agree to hold harmless The Center Helping Obesity In Children End Successfully, Inc., The First Church Development Corporation, the organizers, sponsors, volunteers, as well as the administration of each of them from any claim, demand or action arising out of, or in any way related to the camp, including but not limited to, an injury to my child. In the event of injury, the staff is authorized to obtain any medical care or treatment deemed necessary. By signing, the below box, I acknowledge that I have read and agree to the waiver and release of liability.

Signature of Camper’s Parent or Guardian Date