Camp MariposaYouth Application

Please fill out the form below.

Camp Mariposa Program: *

Alumni
Teen
Junior Counselor
Camper (Youth ages 9-12)

Youth Applicant Information

Applicant's Name: *

First

Middle

Last

Prefered Nickname (if any):

Layout

Date of Birth: *

Age: *

Gender:

Female
Male
Nonbinary/Nonconforming
Prefer to self-describe

Street Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone: *

Email: *

Youth Applicant T‐shirt style: *

Youth Size
Adult Size

Has the youth applicant ever spent the night away from home? *

The following information is used to gather demographic statistics.

Does the youth applicant qualify or receive free lunch at school? *

Has the youth applicant ever been involved with the juvenile justice system? *

Has the youth applicant ever received services from this organization? *

Youth Activities

Is the youth applicant currently in counseling? *

Youth Family Information

Please indicate the type of substance(s) the youth applicant’s family member(s) has struggled with (check all that apply): *

Youth applicant has a family member/guardian in the military (past or present): *

Youth Applicant History

Camp Mariposa has been providing services for youth and families experiencing issues such as addiction, poverty, abuse and mental health for over a decade. We recognize the following questions may be sensitive information to share, but this will help us plan and prepare a program that will benefit all youth. In the event of current abuse of any type, Camp Mariposa staff are mandated reporters.

Mental Health

Has youth applicant or anyone in his/her family experienced mental health issues? *

Abuse/Neglect

Has youth applicant experienced abuse? *

Foster Care/Kinship Care

Has the youth applicant been in foster or kinship care? *

Grief/Loss

Has the youth applicant experienced grief or loss such as loss due to death, separation or incarceration? *

Parent/Guardian Contact Information

Name: *

First

Middle

Last

Prefered Nickname (if any):

Layout

Date of Birth: *

Age: *

Gender:

Female
Male
Non-conforming/Nonbinary
Prefer to self-describe

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone: *

Email: *

Relationship to applicant: *

Emergency Contacts

Please list two people other than you to contact in case of an emergency at camp.

Emergency Contact #1 - Name: *

Relationship to applicant: *

Preferred Phone Number: *

Phone Type:

Cell
Home

Emergency Contact #2 - Name: *

Relationship to applicant: *

Preferred Phone Number: *

Phone Type:

Cell
Home

Additional Youth Information

Please list any special needs or physical challenges the youth applicant has: *

Please tell us what it would mean for the youth applicant to participate in the Camp Mariposa program: *

Please list any hobbies/interests the youth applicant has: *

Acknowledgment

Camper: *

I understand that Camp Mariposa is a yearlong program. I will make every effort to attend each weekend camp and a majority of the activities that will be held during the coming year.

Junior Counselor: *

I understand that the Junior Counselor program is a leadership program for Camp Mariposa alumni interested in gaining valuable experience by assisting staff and supporting campers. I will make every effort to attend all weekend sessions I am invited to and a majority of the additional activities that will be held during the coming year.

Teen Alumni: *

I understand that as a teen participant of the Camp Mariposa teen program, I will be invited to attend special activities. I will make every effort to attend all activities during the coming year.

Parent/Guardian Signature: *

Date: *

Want to Get Involved?

Aaron’s Place needs people like you to help as mentors, camp facilitators, and volunteers.

Camp MariposaYouth Application

Youth Applicant Information

Youth Activities

Youth Family Information

Youth Applicant History

Mental Health

Abuse/Neglect

Foster Care/Kinship Care

Grief/Loss

Parent/Guardian Contact Information

Emergency Contacts

Additional Youth Information

Acknowledgment

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