NORTHERN LIGHTS ECO ADVENTURES SUMMER APPLICATION

https://amandaleighrenslow.typeform.com/to/UWtSP3

You go to the link above to fill out the application online. You can also print and mail the application to 6117 Forest Ave Gary, IN 46403

Northern Lights Eco. Adventures

Ages: 12-15

Cost: sliding scale fee

scholarships available
JUNE 18-22

Do you enjoy nature? Do you like physical activity?

How about working in a team? Do you enjoy service work?

Are you 12-14 years old? Do you like riding a bikes?    

                    Would you like to learn to paddle a craft?

If you answer yes to all of these questions, then you would be a perfect candidate for this summer’s Service Camp.
Spend 4 nights and 5 days trekking through the Indiana Dunes! Start in Michigan City and end at Miller.
Participate in service work by clearing trails, working in local communities, and more.
Create a service project for returning home. Learn about native plants, animals, cultural history, and more!
Build friendships with youth around the Lake Michigan Region.

There are only 10 spots available!      Deadline June 12, 2018 at noon

Total cost: $500.00 (scholarships available)

If you are interested in participating in the program please fill out the following forms.

medical form/health history, student details, emergency contact, application, and reference letter

The camper will be accepted based on application essay and references. If we have 20 campers
that are suitable candidates we will program two camps.

Optional scholarship opportunities: Please provide a essay on the service project you will attend to
provide for your community when returning home. Why it is important for your community.
How and when you plan to implement the activity. How much money you are requesting?

You can email the answers to your medical form/health history, student details, emergency contact,
application, behavior contract, and references to northernlightsecoadventures@gmail.com or mail to
Northern Lights Eco Adventures Inc. 6117 Forest Ave Gary, IN. 46403

Gear List

-day pack             -rain gear -sleeping bag          -flash light/head light

-bowl/spoon                   -tooth brush/tooth paste       -sun block

-sun hat                     -big heavy duty trash bags        -2 shorts non cotton

-5 shirts non cotton   -long sleeve non cotton shirt         -light weight jacket

-non cotton pants           -bathing suit -towel           -soap (small bottle)

-old tennis shoes or boots         -camp shoes

Bug spray

Optional:   Camera journal          

Do not bring

Candy or food, electronics, illegal substances, make up, hair drier (etc)

Student Details

Student Name & Email

Student First Name _______________________	Student Last Name________________	Email___________
Phone___________________	Birthdate (MM/DD/YYYY)____________	Age at Enrollment_____
Gender Male Female

Student Address

Street_____________________________

City_____________________________

State________________________

Zip Code________________________

Country____________________________

How did you hear about us?

_________________________________________________________________________

What school do you currently attend?__________________________________________

If applicable, who referred you to our programs? ____________________________

Primary Emergency Contact

Name_________________	Relationship_______________
Email__________________	Phone________________

Secondary Emergency Contact

Name__________________	Relationship______________
Email___________________	Phone________________

Tertiary Emergency Contact

Name_________________	Relationship______________
Email_____________	Phone_______________

Northern Lights Eco Adventures is designed to be a fun and challenging experience. On course,
participants will form a team and learn to travel through and live in the woods for period of time.
Prior outdoor experience is not necessary for the program.

Please take a few minutes to respond to the following questions related to the applicant’s health
history. This questionnaire is required to finalize your registration, your responses will be kept
confidential, and will help determine the materials included in your enrollment packet.
After submitting this completed registration and application, you will be emailed by a representative
from the company to update your status on the program.

If you have any questions, please email at northernlightecoadventures@gmail.com

Health History Questionnaire

Relationship to Student? Parent Other   *

Height (ex. 5ft 10in)*__________

Weight (in pounds)*___________

Does the Student have asthma? Yes No   *

Does the Student have diabetes? Yes No   *

Does the Student have cardiac issues? Yes No   *

Does the Student have a seizure disorder/epilepsy? Yes No   *

Does the Student have a bleeding or blood disorder? Yes No   *

If yes, please specify:

Does the Student have current orthopedic (bone/joint) issues?

Yes No   *

If yes, please describe:

Has the Student been in counseling in the past year? Yes No   *

If yes, what is/was being addressed?

Is the Student taking any medications? Yes No   *

Please list any medications the Student is currently taking:

Within the past year has the Student been in trouble at school or with the law?

Yes No   *

If yes, please describe:

Does the Student have specific dietary requirements/intolerances (other than vegetarian), such
as vegan or kosher? Yes No   *

If yes, please specify:

Does the Student have any allergies that require the use of an EpiPen, cause hives or difficulty
breathing? Yes No   *

Is there anything else that would be helpful for Northern Lights Eco Adventures Inc. to know that
has not been asked? Yes No   *

If yes, please explain:

Application and 2 references

1. Why would you like to participate in this program?
2. What are some positive attributes you could bring to the program?
3. Explain challenges you expect you might face during your trip?
4. What service project would you like to create upon returning home?

References

Please have a non-family member fill out the form and write a letter explaining why you think this
youth would be an ideal candidate for this program and challenges you foresee for this youth in the
program?

	Excellent	Good	Satisfactory	Below Average	Poor
General Conduct
Work Performance
Attitude to Work
Initiative
Ability to stay on task
Relationships with peers:
Relationships with adults or authority :

Waiver and Release Form

Waiver and Release Form for Summer Camp Liability Release and Parental Consent Form In consideration of the acceptance of my application for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in said event. This release is intended to discharge in advance S.A.S. (Summer Adventures and Service Camp) Northern Lights Eco Adventures, its officials employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees. Parental Consent (Complete if applicant is under 18) I give consent for my child _______________________________ to participate in the above activities, and I execute the above liability release on their behalf. Consent for Treatment I hereby give my consent to have the above applicant treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that  will provide e S.A.S. (Summer Adventures and Service Camp) Northern Lights Eco Adventures no medical insurance for such treatment, and that the cost thereof will be at my expense. I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions. ________________________________ ______________________ ____________ Parent/Guardian Signature Print Name Date ________________________________ ______________________ ____________ Camper Signature Print Name Date