2025 October Camp: Camper Registration Form

Participant Information

This registration form must be completed by a legal guardian.
Youth to Youth Camper Registration

October Camp 2025
Registration Type*
Preferred Name*
First name only. This name will appear on ID badge.
Legal Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
T-Shirt Size*
T-Shirts are in adult sizes.
Participant is a member of UMADAOP youth group. Participant will be transported to/from camp with UMADAOP. (If your participant is being transported to/from camp on the Summit County Y2Y bus check "No".)*

YesNo
Participant's date of birth*

MonthDayYear
Date
Participants Grade*

5th6th7th8th
School the participant currently attends*
School Name
The participant will be assigned to which dorm.*

BoysGirls
Is there anything you want us to know about the participant to make their camp experience great? (i.e. sensory issue, will bring noise cancelling headphones.)

Youth to Youth Camper Registration Form
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Cell Number*
Please enter a valid phone number.
Parent/Guardian Alt. Number
Please enter a valid phone number.
Parent/Guardian E-mail*
Does the Parent/Guardian filling out this form live at the same address as the youth participant.

YesNo
Parent/Guardian Address

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contact Information

Emergency contacts should not include the parent or guardian filling out the form. Should there be an emergency, the parent/guardian will be the first point of contact. If they cannot be reached we will then reach out to the emergency contacts listed below.
Emergency Contact #1
Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Emergency Contact #2
Name*

First NameLast Name
Relationship*
Phone Number*
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Alt. Phone Number
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Camp Information Packet
Please Download or Print

Parent/Guardian Consent Forms
Informed Consent and Acknowledgement

I understand that upon my child’s acceptance for Summit Co. Youth to Youth (Y2Y) I will be responsible for a NON-REFUNDABLE registration fee.

I understand that my child's school is NOT providing transportation. I understand that I will be responsible for the transportation of my child to and from the bus pick-up and return point. If your child is not picked up within the hour of the bus arriving, the local police department will be contacted.

I understand that my child may be photographed and/or videotaped at any Summit Co. Y2Y functions, and that these photos may be used publicly for the promotional purposes of Summit Co. Y2Y. These photographs and/or videotapes are the property of the CHC/Y2Y, and may be placed on the web site, social media, promotional videos, etc. This includes photographs or video of your child during Y2Y club at their school.

For the safety of your child and the other participants of the program it is essential that all parents/guardians and students take the time to read the Camp Information Packet, which includes the rules for camp and the “what to bring, what not to bring” information. This document in embedded in this registration form and will be emailed upon completion of this registration. I understand that if my child breaks any rules, or brings any items on the “Things not to bring list,” that I will be phoned immediately and will need to arrange transportation home from Camp Muskingum in Carrollton, Ohio.

The goal of Summit Co. Youth to Youth is to begin to educate young people, not only about the dangers of drug/alcohol abuse and use, but also about peer pressure, decision-making, self-esteem, problem gambling, etc.

Youth to Youth is NOT a drug treatment or rehabilitation program.

CHC is an equal opportunity employer and provider of services. We do not discriminate on the basis of race, religion, gender, gender identity, sexuality, physical or academic abilities, etc.

If your child requires any accommodations, please include in the space provided in this form. Please note: all gendered assignments are based on the gender identity of the camper/youth staff.

I have read the rules and understand my responsibilities as the parent/guardian of a participant in the Summit Co. Youth to Youth Program.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

Clear

Medical Release and Authorization

I understand that necessary precautions and plans for the care and supervision of the minor participants will be observed. Therefore, I assume there are unpredictable risks involved, and I release CHC/Y2Y, and its appointed personnel from any responsibility in the case of illness, accident, injury and/or emergency first aid administered to my child. I further give my permission that my child may be treated by any physician, hospital, or other medical facility.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

Clear

Goal and Mission

Payment Page
“Summit County Y2Y is a diverse group of youth creating change through educating and promoting healthy and drug-free decision making while providing a welcoming and accepting environment.” - Mission Statement formed collaboratively by the 2022-2023 Summit County Youth to Youth staff.
We, at Summit County Youth to Youth, want to give all students who want to be a Y2Y camper the oportumity to come to camp! If the payment below is cost prohibitive for your family, please contact Lauren Munk, lauren.munk@chcakron.org, for scholarship/coupon options.

Registration Fees*

5th-8th Grade Campers

$100.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Participant Information

Youth to Youth Camper Registration

Youth to Youth Camper Registration Form

Participant Demographic Information

Emergency Contact Information

Emergency Contact #1

Emergency Contact #2

Medical Information

Prescription and Over-the-Counter Medications Details

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication Authorization

Camp Information Packet

Parent/Guardian Consent Forms

Goal and Mission