MHABC Summer Camp

Parent Name #1*

First Last

Parent Name #2

First Last

Parent #1 Address*

Street Address Address Line 2 City State ZIP Code

Parent #2 Address*

Street Address Address Line 2 City State ZIP Code

Parent #1 Email*

Enter Email Confirm Email

Parent #1 Phone*

Parent #2 Email*

Enter Email Confirm Email

Parent #2 Phone

Child Enrollment*

How many children do you want to enroll in the MHABC Summer Camp?

Child #1 Name*

First Last

Child #1 Birthdate*

Child #2 Name*

First Last

Child #2 Birthdate*

Child #3 Name*

First Last

Child #3 Birthdate*

Child #4 Name*

First Last

Child #4 Birthdate*

Weeks to Attend*

Please select the dates your child(ren) will attend Summer Camp by selecting all that apply. Summer Camp is closed on May 26 and July 4.

Authorized pick-up person(s)*

All authorized pick-up persons must be registered. How many authorized pick-up persons do you want to register?

Authorized Pickup Person #1*

Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.

First Last

Authorized Pickup Person Phone #1*

Authorized Pickup Person #2*

Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.

First Last

Authorized Pickup Person Phone #2*

Authorized Pickup Person #3*

Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.

First Last

Authorized Pickup Person Phone #3*

Authorized Pickup Person #4*

Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.

First Last

Authorized Pickup Person Phone #4*

Child(ren) Allergies*

Type child's name plus each allergy, type NA if none (see format below)

Medical Needs*

Type child's name plus each medical need, type NA if none (see format below). If medical administration is needed by our staff, the Medical Release form will need to be signed.

Do you wish to order your child(ren) a summer camp t-shirt ($TBD)?*

Child #1 t-shirt size*

Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large

Child #2 t-shirt size*

Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large

Child #3 t-shirt size*

Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large

Child #4 t-shirt size*

Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large

Payment method*

Please note there will be a convenience fee charged for all electronic forms of payment including credit card, debit card, e-check/bank transfer. Paper checks issued by bank on your behalf are not considered E-checks and are not charged a convenience fee. If you select Debit/Credit Card option below, right click on this link NOW, select “Open link in new tab”, and follow payment authorization steps >> Credit/Debit Authorization

Debit/Credit Card
E-check/ACH Bank Transfer
Paper Check/Bank Check
Other

Hidden

Rules Addendum and Waiver Consent*

I followed the link below and have completed the Rules Addendum and Waiver submission

Right click on this link NOW, select “Open link in new tab”, and follow steps to complete submission >> Rules Addendum and Waiver

Parent Agreement Consent*

I agree to the Parent Agreement below

MHABC SUMMER CAMP PARENT AGREEMENT
PLEASE READ THE FOLLOWING COMPLETELY – YOU ARE MAKING MULTIPLE AUTHORIZATIONS BY SIGNING THIS DOCUMENT, INCLUDING MEDIA RELEASE, GENERAL LIABILTY RELEASE, TRANSPORT RELEASE, MEDICAL RELEASE, and more:
For the MHABC summer camp period (generally, late May-early August), I agree to the following:
1. I will adhere to the attendance weeks chosen herein, and I understand payment is due on the Friday prior to attendance;
2. ANY AND ALL PLAN CHANGES MUST BE MADE WITH A TWO (2) WEEK NOTICE – ONE PLAN CHANGE PER FAMILY PER SUMMER ONLY, PLEASE. ENDING SERVICES ALSO REQUIRES A TWO WEEK NOTICE. ALL CHARGES WILL APPLY AS NORMAL UNLESS A TWO WEEK NOTICE HAS BEEN PROVIDED TO THE MHABC VP OF BUSINESS, BECKY FETTIG AT BFETTIG@MHABOONECOUNTY.ORG. (NOTE: PLEASE DO NOT PROVIDE PLAN CHANGES TO SUMMER CAMP SITE STAFF).
3. I understand that MHABC Summer Camp is an enrollment-based program, and is not an a la carte, daily program. Once my child is enrolled, my fee for services will not change week to week whether my child attends one day per week or 5 days per week except for the weeks I have informed Summer Camp administrative staff at least two weeks in advance that my child will not attend. Refunds are not provided for illness, even if a child is out for an entire week.
4. I understand that charges for the first and final weeks of summer camp will be for a full week, even if these are shorter weeks. I understand this is separate from the BASE enrollment fees if I plan on my child attending the first or last few days of regular school year BASE on the same week. I understand this is due to the administrative costs of both programs, and because both programs are considered distinct from one another.
5. I have read and agree to all policies set forth and included in the Parent Handbook which is available online at www.mhaboonecounty.org.
6. I agree to be responsible for all expenses incurred for medical and/or emergency transportation costs;
7. I authorize MHABC to transport my child for field trips and special activities (such as swimming, clubs, YMCA, etc.) throughout the summer. I recognize and acknowledge that there are certain risks of physical injury associated with being transported by bus/car by an MHABC staff member. I agree to assume the full risk of injuries that may be sustained by any minor child/ward of mine, as a result of being transported by bus/car by an MHABC staff member and all activities connected or associated therewith. I agree to waive and relinquish all claims on behalf of my minor child/ward that the minor child/ward may have against MHABC as a result of the minor child/ward’s being transported by bus/car/other vehicle by an MHABC staff member.
8. I have provided all necessary information regarding my child(ren)’s medications, allergies and medical conditions to MHABC. I understand that if my child uses an Epi-pen or similar device, I MUST provide this to the MHABC administration prior to my child’s attendance at summer camp. Any dispensing of medication or Epi-pen administration will require a signed medical form in advance. Form can be found on the MHABC website.
9. I understand that I and the other parent will initially be required to present a photo I.D. when picking up my child until site staff becomes familiar with us. I understand that when a person other than myself or the other parent will be picking up my child, that individual needs to provide a picture ID in order to be permitted to pick the child up. I further understand that if I need to make a change to the authorized pickup list, I must do so in writing to PFETTIG@MHABOONECOUNTY.ORG by using the email listed on my MHABC/BASE account, preferably with a 24-hour notice. If I am unable to give a 24-hour notice of a change, I will call the MHABC office at (765) 482-3020 x100 and inform staff of the change, and also do so in writing to PFETTIG@MHABOONECOUNTY.ORG
10. I understand that if a custody or a protective order are an issue affecting who may or may not pick up my child(ren), I will IMMEDIATLY communicate this to MHABC administration at 765-482-3020 x100 and provide a copy of the relevant court order to PFETTIG@MHABOONECOUNTY.ORG. I understand that without a court order stating otherwise, MHABC staff cannot prevent a legal parent from picking up a child.
11. I understand that all MHABC staff are mandated to report any signs of abuse or neglect;
12. MHABC will adhere to directives set forth by local, state and federal health officials regarding any illnesses. MHABC reserves the right to close any program temporarily should public health protocols warrant and/or MHABC believes a shutdown to be in the best interest of students and staff.
13. I understand MHABC reserves the right to exclude any child from summer camp or request that a child be picked up from camp should the child be exhibiting symptoms of a transmissible illness. I understand this could affect my childcare plans and that I should have backup plans in place should this occur.
14. I understand that my child may be denied enrollment until the registration and all pertinent acknowledgments and forms are submitted, and that submitting this form in close proximity to the time at which I need my child(ren) to begin the program could impact my child(ren)’s start date.
15. I understand my child(ren) can be denied attendance in the case of non-payment.
16. I understand that a $15/week late fee may be added each Monday as a result of an unpaid invoice.
17. I understand that I must pick my child(ren) up before 6:00 p.m. or a $8.00/minute, per child fee will accrue and I will be expected to make payment immediately to the MHABC site staff or the next business day to MHABC administrative staff.
18. I/we, the parent(s) of the registered child(ren) acknowledge that I/we are responsible for any unpaid balance for attendance fees, late fees, and finance charges associated with my/our account;
19. I/we, the parent(s) of the registered child(ren) acknowledge that I/we are responsible for attorney’s fees required for purposes of collection of any unpaid fees herein, plus any and all costs of collection, including court fees.
20. I/we agree to contact MHABC administration at (765) 482-3020 x100 with any and all questions related to this document.

I hereby authorize MHABC staff to capture, edit, and use my child’s video and/or photographic image solely for the purposes of sharing information about the MHABC youth programs and for promoting and advertising the program on the MHABC social media pages and website, in newspapers and newsletters, via e-mail and via other forms of media. In doing so, I release MHABC and its staff, representatives, board members, and agents from all claims, demands and liabilities whatsoever in connection with the above. PARENT: If you do NOT want your child’s image used in this manner, please email PFETTIG@MHABOONECOUNTY.ORG within 48 hours of submitting your registration and advise you do not want your child’s image used. Please maintain record of such communication.

Medical Treatment Release: I hereby consent to emergency medical treatment of my child(ren) herein registered, during MHABC Summer Camp operation hours, should I not be able to be reached, to ensure prompt treatment and prevention of undue delay. I understand such treatment, other than first aid required to be rendered immediately by an MHABC staff member, will be provided by either a licensed physician or individual trained in emergency care.

General Liability Release: I, individually, and on behalf of my minor child(ren) and our respective heirs, successors, assigns, and personal representatives, hereby release, acquit, indemnify, hold harmless and forever discharge Mental Health America of Boone County and their administration, staff, site leaders, designated volunteers, agents, board members, officers, trustees, and representatives (in their official and individual capacities) from any and all liability whatsoever for any and all damages, losses, injuries or illnesses, including death, to persons or property or both, including but not limited to any claims, demands, actions, causes of action, damages, costs, expenses and attorney’s fees, which arise out of, during or in connection with my child(ren)’s participation in MHABC’s programs. I agree the General Liability Release above is intended to be as broad and inclusive as permitted by the laws of the State of Indiana and if any portion is held to be invalid, it is agreed the balance of the release will continue in full force and effect.

In signing the Release, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provisions, that I understand it affects my legal rights and those of my child (or children), that it is a binding agreement, and that I have signed it knowingly and voluntarily.

Parent Signature*

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2025 MHABC Summer Camp Registration

*New price:

$125/wk per child (check and cash payment)

$129/wk per child (credit card payment)

(Weekly price is same regardless of number of days attended per week – see parent agreement)

*New location:

Boone Co. 4-H Fairgrounds (Advantage Building)

1300 E. 100 S.

Lebanon, IN 46052