Overnight Sessions / Camp Application / 2023

Since 2002, Camp Get-A-Way has been a place where you and your kids can play, connect, create, and bond in the great outdoors. Try new things like archery, swimming, fishing, and canoeing as a family. Share laughter and s’mores by the campfire. Create memories over tie-dye fun, camp crafts, and games. Find hope through the family resources and training. And start lasting friendships with other New York families facing similar challenges.

We know life often doesn't feel "normal" when you have a child struggling with an emotional, behavioral, or mental heath challenge. That’s why Camp Get-A-Way comes alongside families like yours to create a safe camp experience where families can just be families.

Please be sure to read through the application to be certain you have all the documentation you need. Camp sessions are scheduled on a first come, first served basis. Space is limited. A complete list of eligibility criteria is available by contacting Camp Get-A-Way. Each family member MUST have a medical history form and physical or letter from Doctor office.

2023 SESSIONS:
- August 20-23, 2023 • Canandaigua, NY
- August 27-30, 2023 • Ithaca, NY
- September 15-17, 2023 • Huguenot, NY
- October 13-15, 2023 • Riverhead, NY
CAMP COSTS:
Camp costs:
- $450.00 per family (for a family of up to five people; $50 per additional person)
- $25.00 non-refundable application fee
- Applications and complete payment are due 30 days prior to the start of the session for which you registered.
TRANSPORTATION:
Due to very limited staff availability, every effort should be made by the family and with their service provider to arrange transportation directly to Camp.

DIETARY NEEDS:
Please include special medically prescribed dietary needs with your application materials and notify CGAW at least one week before camp if anyone’s dietary needs have changed. In addition, other dietary accommodations will be considered on a case-by-case basis with advance notice.

Have questions? Visit cgaw.org/faqs or contact us at hello@cgaw.org.

We look forward to seeing you in 2022!

Sincerely,

Ken Tangel, President
family information
Family Name*
Name of adult completing this application *

First NameLast Name
Primary Language*
Number of adults (18+) attending camp*
Number of children attending camp*
Please check Camp Session you are applying for; show your first and second choice. Every effort will be made to accommodate the desired session; applications are processed on a first come basis based on completion and payment received.*

August 20-23, 2023 (Canandaigua, NY)August 27-30, 2023 (Ithaca, NY)September 15-17, 2023 (Huguenot, NY)October 13-15, 2023 (Riverhead, NY)

Adult #1 (Adult completing camp application)*

First NameLast Name
Date of Birth*

MonthDayYear
Relationship to Child*
Email*

Confirmation Emailname@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone*

Area CodePhone Number
Type of Phone*

MobileHome
Shirt Size*

Adult #2*

First NameLast Name
Date of Birth*

MonthDayYear
Relationship to Child*
Email*

Confirmation Emailname@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone*

Area CodePhone Number
Type of Phone*

MobileHome
Shirt Size*

Adult #3*

First NameLast Name
Date of Birth*

MonthDayYear
Relationship to Child*
Email*

Confirmation Emailname@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone*

Area CodePhone Number
Type of Phone*

MobileHome
Shirt Size*

Adult #4*

First NameLast Name
Date of Birth*

MonthDayYear
Relationship to Child*
Email*

Confirmation Emailname@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone*

Area CodePhone Number
Type of Phone*

MobileHome
Shirt Size*

Child #1*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #2*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #3*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #4*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #5*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #6*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #7*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #8*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #9*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #10*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #11*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child #12*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Shirt Size*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

provider information and recommendation application
Provider Information*

Before my application is considered, I understand that my Family Support or Children's Mental Health Provider must submit a recommendation application. By providing their information and email address below, I understand that my provider will receive the recommendation application via email to complete on my behalf.
Provider Name*

First NameLast Name
Agency*
Provider Email*

Confirmation Emailexample@example.com
Fax Number*

Area CodePhone Number
Phone Number*

Area CodePhone Number

safety, concerns, and needs

These questions are asked not as a rule out for acceptance to CGAW, but so that we can better serve each and every member of your family, as well as provide for the safety and well being of all campers. Please identify all areas (past or present) that apply for EACH member of your family attending camp this year.
Poor self care
If so, please identify which family members above.
Violent/aggressive behavior
If so, please identify which family members above.
Cruelty to animals
If so, please identify which family members above.
Stealing
If so, please identify which family members above.
Fire setting
If so, please identify which family members above.
Conviction of a crime
If so, please identify which family members above.
Self-harming behavior
If so, please identify which family members above.
Drug/alcohol problems
If so, please identify which family members above.
Delusional thoughts
If so, please identify which family members above.
Runaway/leave without permission
If so, please identify which family members above.
Sexual misconduct
If so, please identify which family members above.
Suicidal/homicidal ideation
If so, please identify which family members above.
Restraining order
If so, please identify which family members above.
Order of protection
If so, please identify which family members above.

consents, disclaimers, and releases
Consent for Emergency Medical Care and Emergency Contacts (required)

I, {adult13}, give my consent for Camp Get-A-Way or any person acting as the agent for Camp Get-A-Way to seek emergency medical care for the following family members:
- {adult13}
- {adult2143}
- {adult3}
- {adult4}
- {child1}
- {child2}
- {child3}
- {child4}
- {child5}
- {child6}
- {child7}
- {child8}
- {child9}
- {child10}
- {child11}
- {child12}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear
Witness Signature*
Date*

MonthDayYear

in case of emergency...

Please list three people we may contact.
Emergency Contact #1*

First NameLast Name
Relationship to Emergency Contact #1*
Emergency Contact #1 – Phone*

Area CodePhone Number
Emergency Contact #2*

First NameLast Name
Relationship to Emergency Contact #2*
Emergency Contact #2 – Phone*

Area CodePhone Number
Emergency Contact #3*

First NameLast Name
Relationship to Emergency Contact #3*
Emergency Contact #3 – Phone*

Area CodePhone Number

disclaimers
Confidentiality Statement (required)

The Camp Get-A-Way team agrees to treat knowledge of any confidential information in a secure manner and to use the information only for the purpose for which it was shared. It is Camp Get-A-Way’s belief that what is talked about and shared during the camping experience among participating families and staff will remain confidential after families and staff returns to their homes.

Family members covered by this consent:
- {adult13}
- {adult2143}
- {adult3}
- {adult4}
- {child1}
- {child2}
- {child3}
- {child4}
- {child5}
- {child6}
- {child7}
- {child8}
- {child9}
- {child10}
- {child11}
- {child12}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear
Witness Signature*
Date*

MonthDayYear
Liability Disclaimer (required)

I, {adult13}, hereby release Camp Get-A-Way, its officers, volunteers, and family participants from any liability that might occur while participating in the programs offered during my time at Camp Get-A-Way.

Family members covered by this consent:
- {adult13}
- {adult2143}
- {adult3}
- {adult4}
- {child1}
- {child2}
- {child3}
- {child4}
- {child5}
- {child6}
- {child7}
- {child8}
- {child9}
- {child10}
- {child11}
- {child12}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear
Witness Signature
Date

MonthDayYear
Consent for Taking and Releasing Photographs and Video (optional)

I, {adult13}, give consent to the taking of photographs and/or video either arranged by or taken by Camp Get-A-Way. I give this consent and release to use my photographic likeness in all forms, media, and any other lawful purposes for the advancement of Camp Get-A-Way.
Family members covered by this consent:
Family members NOT covered by this consent:
Signature
Date

MonthDayYear
Witness Signature
Date

MonthDayYear

support team
My family is supported by a (check all that apply):

Community Mental Health ProviderFamily Support ProgramN/A

community mental health provider
Provider Name*

First NameLast Name
Agency*
Provider Email*

Confirmation Emailexample@example.com
Provider Fax Number*

Area CodePhone Number
Provider Phone Number*

Area CodePhone Number
Consent for Release and Exchange of Information with Community Mental Health Provider:

This consent will be in effect November 10, 2020.

I, {adult13}, give consent to Camp Get-A-Way to release and exchange information with my community mental health provider listed below:

Provider Name: {providerName}
Agency: {agency}
Provider Email: {providerEmail}
Provider Fax: {providerFax}
Provider Phone: {providerPhone}

_______________________

Family members covered by this consent:
- {adult13}
- {adult2143}
- {adult3}
- {adult4}
- {child1}
- {child2}
- {child3}
- {child4}
- {child5}
- {child6}
- {child7}
- {child8}
- {child9}
- {child10}
- {child11}
- {child12}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear
Witness Signature*
Date*

MonthDayYear

family support program
Provider Name*

First NameLast Name
Family Support Program*
Provider Email*

Confirmation Emailexample@example.com
Provider Fax Number*

Area CodePhone Number
Provider Phone Number*

Area CodePhone Number
Consent for Release and Exchange of Information with Family Support Program:

This consent will be in effect November 10, 2020.

I, {adult13}, give consent to Camp Get-A-Way to release and exchange information with {familySupport} Family Support Program

Provider Name: {providerName263}
Agency: {familySupport}
Provider Email: {providerEmail265}
Provider Fax: {providerFax266}
Provider Phone: {providerPhone267}

_______________________

Family members covered by this consent:
- {adult13}
- {adult2143}
- {adult3}
- {adult4}
- {child1}
- {child2}
- {child3}
- {child4}
- {child5}
- {child6}
- {child7}
- {child8}
- {child9}
- {child10}
- {child11}
- {child12}
Printed Name: {adult13}
Relationship: {relationshipTo118}
Signature*
Date*

MonthDayYear
Witness Signature*
Date*

MonthDayYear

expectations of camp get-a-way
Camp Get-A-Way has developed the following basic list of expectation to ensure a safe, healthy, and fun camping experience for everyone involved. Any violation of these rules may result in a family’s dismissal from Camp Get-A-Way. All concerns will be reviewed by the Board and all decisions made are final.
- Children are the sole responsibility of their parents/guardians at all times.
- No child of any age can be unsupervised at any time.
- Parents / guardians must know where their children are at all times.
- All children 15 years old and younger must have direct adult supervision at all times.
- Children 16 years old and older: Must be in direct visual contact of an adult at all times.
- Parent/guardian will be responsible for any damage or destruction caused while at camp.
- Smoking is allowed only in designated area(s) of camp. Anyone smoking in non-designated areas will be asked to leave Camp. Absolutely NO smoking in or around the cabins. Children are not allowed in the smoking shelter.
- No possession or consumption of illegal drugs, or being under the influence of illegal drugs is allowed in camp.
- No alcohol, alcohol consumption, or being under the influence of alcohol is allowed while at camp.
- No weapons are allowed in camp.
- No stealing.
- No physical or verbal aggression towards others.
- No one may leave camp while camp is in session without signing in and out at Nurses Station.
- All medications MUST BE IN THEIR ORIGINAL CONTAINERS (prescription and over the counter, with certain exceptions) and will be locked in the Nurse’s Cabin at all times.
- No swimming without lifeguard on duty. Waterfront Activities require direct adult supervision for all camp participants.
- Campfires only in designated area.
- All family members are expected to participate in family activities, camp upkeep, and dining hall chores.
- Quiet time is from 10:00pm until 7:30am.
- Families are encouraged to keep a copy of the rules, which will be posted throughout camp and are available on the Camp Get-A-Way website.
It is very important that everyone understands the expectations before arriving at Camp Get-A-Way. The expectations are to ensure the safety of all campers, volunteers and staff. By signing below, we acknowledge that we have read and reviewed this with all family members that will be attending and received a copy of the expectations of Camp Get-A-Way.
Print name of signer #1*

First NameLast Name
Signature #1*
Date*

MonthDayYear
Print name of signer #2

First NameLast Name
Signature #2
Date

MonthDayYear
Print name of signer #3

First NameLast Name
Signature #3
Date

MonthDayYear
Print name of signer #4

First NameLast Name
Signature #4
Date

MonthDayYear

medical information

PLEASE COMPLETE THE FOLLOWING FORMS FOR EACH CAMPER.

family information

your camp experience

provider information and recommendation application

safety, concerns, and needs

consents, disclaimers, and releases

in case of emergency...

disclaimers

support team

community mental health provider

family support program

expectations of camp get-a-way

medical information

medical history

mental health service providers

medical history

mental health service providers

medical history

mental health service providers

medical history

mental health service providers

medical history

mental health service providers

medical history

mental health service providers

	Medication	X's Per Day	Dosage

	Medication	X's Per Day	Dosage

	Medication	X's Per Day	Dosage

	Medication	X's Per Day	Dosage