Minuteman Youth Camp

2024 Camp Application

Sunday July 28th – Friday August 2nd
DEADLINE for SUBMITTING APPLICATION – May 31, 2024

1Camp Application

2Meet My Child Worksheet

A maximum of 75 campers will be accepted this year. First priority will be given to children with parents or extended family in the Arkansas National Guard and other branches of the military. Camp is open to children ages 10-12. Camper must be at least age 10 before July 28, 2024 and not turn 13 before August 2, 2024. A child may only attend Minuteman Youth Camp ONCE. Children residing out of the state MUST have a military affiliation and be spending a majority of the summer in Arkansas.

SECTION I: CHILD'S INFORMATION

Child's Name(Required)

First Middle Last

Address(Required)

Street Address Apt / Line 2 City State ZIP Code

T-Shirt Size(Required)

Adult Men's Sizes

SECTION II: PARENT or LEGAL GUARDIAN INFORMATION

Name(Required)

First Last

Place of Work

Cell Phone(Required)

Daytime Phone

Evening Phone

Primary Email(Required)

Secondary Email

This email address will receive duplicate info.

Name of the Unit or Wing that family member or military sponsor is assigned to(Required)

Armed Forces member’s name(Required)

Relationship(Required)

SECTION III: MEDICAL INFORMATION

If special arrangements or accommodations should be made/planned ahead of the camp, please contact the Minute Man Youth Camp. If your child has allergies, medication needs, or any other medical condition we need to be aware of during camp, please complete the information below. Please include all prescription and/or over-the-counter medication information. The parent should dispense all medication while child is participating in the camp (See exception below)*.

Does your child require an aid?(Required)

Yes

Medical Information / Needs that require monitoring

Allergies to food/medicine(Required)

Dietary Restrictions(Required)

* If your child typically self-medicates, please indicate your permission for him/her to do so while attending MMYC.

Self-medicate

My child has permission to administer his/her own medication during MMYC.

Please list any special storage needs

The Minute Man Youth Camp staff will make every effort to contact you in the event of an injury. Should you not be reachable, or if the emergent situation dictates, we will act on your behalf in seeking medical care for your child.

AUTHORIZATION/CONSENT TO TREAT(Required)

I, the parent/legal guardian, authorize and consent to medical, surgical, hospital care, treatment and procedures to be deemed immediately necessary or advisable by the physician to safeguard my child’s health during the Minute Man Youth Camp. I waive my rights of informed consent to such treatment. I also authorize a copy of this consent to be treated with the same authority as the original one.

I agree to AUTHORIZATION/CONSENT TO TREAT

HOLD HARMLESS(Required)

By signing this form, I, the parent/legal guardian, voluntarily agree and affirm to assume all risks associated or arising during transportation to and from the activity and during my participation in this activity. Further, I, my heirs, successors, assigns and personal representative(s), hereby agree to release the Minute Man Youth Camp, the United States Government, Cognitive Professional Services, Columbus Technologies and Services, Inc., their board, officers, agents and employees from any and all liability, loss, damage and expenses, including reasonable attorney fees, which may arise on account of damage to personal property or personal injury or death resulting from my transportation to and from or participation in this activity.

The following safety criteria MUST be adhered to by all passengers:

• Seatbelts shall be worn at all times.

• Use of alcohol, drugs, other harmful, and illegal substances are strictly prohibited.

• The use of tobacco products are prohibited.

• Any actions that are distracting to the driver or prevent the driver from safe vehicle operation are prohibited.

• Arms and legs will not be extended from the vehicle at any time the vehicle is in motion.

• Directions of the driver will be adhered to at all times.

I agree to HOLD HARMLESS

SECTION IV: PHOTO AND NON-CONFIDENTIAL INFORMATION RELEASE

PHOTO AND NON-CONFIDENTIAL INFORMATION RELEASE(Required)

I, the parent/legal guardian, understand that the Minute Man Youth Camp and/or National Guard or Cognitive Professional Services, Inc, Columbus Technologies and Services, Inc. in various states or other multimedia materials, will illustrate activities in which youth, volunteers and others participate at training. I grant the AR NG and/or its associated staff and subordinate entities, the right to take, use, reproduce, assign and/or distribute photographs, films, non-confidential information, videotapes, and sound recordings of me or my child for use in any such materials as the AR NG or its associated entities may create, without any payment to or future approval by me. I concur there shall be no payment for such use.

I agree to PHOTO AND NON-CONFIDENTIAL INFORMATION RELEASE

BIRTH CERTIFICATE

A copy of the Camper’s Birth Certificate must be attached to this application. You may take a picture of the child's birth certificate with your phone and upload it here.

Upload Birth Certificate(Required)

Max. file size: 10 MB.

SIGNATURES

Signature of Youth Representative(Required)

Signature of Parent or Legal Guardian(Required)