• Participant Information

    This registration form must be completed by a legal guardian.

  • Youth to Youth Camper Registration

    Fall Camp 2026
  • Format: (000) 000-0000.
  • Participant will be transported to/from camp with*
  • Participant's date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Participants Grade*
  • The participant will be assigned to which dorm.*

  • Youth to Youth Camper Registration Form

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does the Parent/Guardian filling out this form live at the same address as the youth participant.

  • Participant Demographic Information

    This information is gathered and provided to our funders at the Summit County ADM Board for statistical purposes only.
  • Sex*
  • Ethnicity*
  • Race*

  • 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

    Not the Parent or Guardian filling out this form.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact #2

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical Information

  • The participant is cover under a medical insurance plan.*
  • Over-the-counter medication authorization*
  • The camp nurse may administer the following over-the-counter medications in the appropriate dosage for age/weight of participant. (Check all that apply) Please note: The following medications are provided. Please do not bring these medications to camp.
  • The participant will bring with them prescription medications, over-the-counter medications, or supplements. Please note: all prescription medications, over-the-counter medications, or supplements brought to camp must be turned in to the camp nurse. Participants may not have any medications in their possession, except inhalers and EpiPens.*

  • Prescription and Over-the-Counter Medications Details

    In this sections, only list medication being brought by you to camp. Do not list over-the-counter medications provided by the camp nurse, which are listed above.

  • Medication #1

  • When should med. be given? (Select all that apply)

  • Medication #2

  • When should med. be given? (Select all that apply)

  • Medication #3

  • When should med. be given? (Select all that apply)

  • Medication #4

  • When should med. be given? (Select all that apply)

  • Medication #5

  • When should med. be given? (Select all that apply)

  • Medication #6

  • When should med. be given? (Select all that apply)

  • Medication Authorization

    I give permission to the CHC /Summit County Youth to Youth Nurse to administer the medications designated above to the participant.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Camp Information Packet

    This document contains important information about camp. Please review with participant(s). We recommend that you download and save this document for your reference.
  • Please download and save for your reference.

  • 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*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Camp Rules and Guidelines

    Please read with the camp participant. Both parents/guardians and participants must sign the acknowledgement below.

  • Confirmation

    I HAVE READ, UNDERSTAND, AND WILL ADHERE TO THE CAMP RULES AND GUIDELINES. 

    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*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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*

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      5th-8th Grade Campers
      $100.00$100.00
        
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      Debit or Credit Card
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