Summer Camp 2023

Rising Resilient Summer Camp

July 11th – August 1st, 2023

a free summer camp for youth who attended in 2022

Ages: 10 – 14 years
Days: Tuesdays
Time: 9:00 AM – 4:00 PM
Activities: Activities / classes will be taught by our staff & volunteer mentors. These will include water play, cooking, DIY, sports, nature crafts, and more!

We are not opening camp to the community at large this year, because of reduced staff and capacity. We are taking this Summer to serve the youth we know are looking forward to camp, hire & train staff, and prepare for programs to resume in Fall 2023.

Youth will meet at Rogue Valley Mentoring’s Nature Center in Lithia & Driveway Fields:
2931 S Pacific Hwy, Medford, OR 97501
*follow signs to “Nature Center” after entering Lithia & Driveway Fields: signs on property say Coyote Trails

Please bring a lunch and water bottle daily. RVM will provide snacks & water for refilling bottles throughout the day.

Summer Programs Registration Form

Please complete a separate form for each youth you would like to register.

"*" indicates required fields

Who is the person completing this form?*

Youth

Parent/Guardian of Youth

Community Partner Referring

Community Partner

Community Partner: Please share your name, organization, and contact information.*

Community Partner: Has the child asked & agreed to participate in this circle?

Yes

No

Youth Information

Youth's Full Name*

First Last

Preferred Name (Nickname)

Youth's Date of Birth*

Youth's Gender*

Male

Female

Non-binary

Other

Youth's Pronouns*

She, her, hers

He, him, his

They, them, theirs

Other

Youth's Race*

Select all the apply:

Youth's School*

Youth Shirt Size*

Will Youth participate in soccer during Summer Camp days, or opt for another activity?*

Soccer

Another Activity (art, games, etc. at Nature Center)

I'm not sure

Does youth have any dietary allergies or restrictions?*

Please, let us know dates of any planned vacations or absences on Summer Camp dates.

Is there anything else the youth would like Rogue Valley Mentoring to know?

Parent/Guardian #1

Parent/Guardian #1 Full Name*

First Last

Parent/Guardian #1 Relationship to Youth*

Parent/Guardian #1 Full Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #1 Phone*

Parent/Guardian #1 Email*

Would you like to enter information for a 2nd Parent or Guardian?*

Yes

No

Parent/Guardian #2

Parent/Guardian #2 Full Name

First Last

Parent/Guardian #2 Relationship Youth

Parent/Guardian #2 Full Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #2 Phone

Parent/Guardian #2 Email

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Relationship to Youth*

Emergency Contact Phone*

Emergency Contact Email

Agreements and Signature

I give my permission, without compensation or time limitation, for Rogue Valley Mentoring (RVM) to use images that include me and my minor child, taken during RVM programs, in promotional or educational materials, both in print or on the Internet.*

Yes

No

I have read and understand the below statement and I am willing to take part in Rogue Valley Mentoring evaluation procedures.*

Rogue Valley Mentoring relies on an evaluation process to inform the quality and effectiveness of services. I understand that Rogue Valley Mentoring will collect information from me using occasional surveys. I also understand that any information received through evaluation will be kept confidential. Furthermore, I understand that my participation in this program’s evaluation process is completely voluntary and that I can choose not to participate in program evaluation and this will not affect my participation in this program.

Yes

No

Send registration confirmation & general communications to this email address:*

Agreement*

By checking 'Yes', I agree that all information provided above is correct. This will act as a digital signature confirming this.

Yes

Email

This field is for validation purposes and should be left unchanged.

Rising Resilient Summer Camp

July 11th – August 1st, 2023

a free summer camp for youth who attended in 2022

Youth will meet at Rogue Valley Mentoring’s Nature Center in Lithia & Driveway Fields: 2931 S Pacific Hwy, Medford, OR 97501 *follow signs to “Nature Center” after entering Lithia & Driveway Fields: signs on property say Coyote Trails

Summer Programs Registration Form

Community Partner

Youth Information

Parent/Guardian #1

Parent/Guardian #2

Emergency Contact Information

Agreements and Signature

Youth will meet at Rogue Valley Mentoring’s Nature Center in Lithia & Driveway Fields:
2931 S Pacific Hwy, Medford, OR 97501
*follow signs to “Nature Center” after entering Lithia & Driveway Fields: signs on property say Coyote Trails