Camp MariposaYouth Application Please fill out the form below. Please enable JavaScript in your browser to complete this form.Camp Mariposa Location *Anderson, SCBloomfield, INChicago, ILDandridge, TNDayton, OHEverett, WASouthwest OHIndianapolis, INIrvine, KYEastern WVNashua, NHNew Orleans, LAPhiladelphia, PASouthern WVSan Diego, CASarasota, FLSouth Bend, INSt. Petersburg, FLSouthwest WAOtherOther Camp Mariposa Location: *Please describeCamp Mariposa Program: *AlumniTeenJunior CounselorCamper (Youth ages 9-12) How did you learn about Camp Mariposa? *CM DirectorCM ParentFriend TherapistSchoolSocial Worker/Case ManagerSocial MediaEluna WebsiteOtherOther: *Please describeYouth Applicant InformationApplicant's Name: *FirstMiddleLastPrefered Nickname (if any):LayoutDate of Birth: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age: *Gender:FemaleMaleNonbinary/NonconformingPrefer to self-describeGender:Please describeStreet Address:Address Line 1Address Line 2CityIndianaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone: *Email: *Youth Applicant T‐shirt style: *Youth SizeAdult SizeYouth Size *SMLXLAdult Size *XSSMLXL2XL3XL4XLHas the youth applicant ever spent the night away from home? *YesNoThe following information is used to gather demographic statistics.Does the youth applicant qualify or receive free lunch at school? *YesNoRace/Ethnicity of Youth Applicant: *African‐American/BlackAmerican Indian/Native AmericanAsianHispanic/LatinoPacific Islander White/Caucasian Multi-racial (please select all race/ethnicities that apply)Other Race/EthnicityRace/Ethnicity of Youth Applicant: *Please describeHas the youth applicant ever been involved with the juvenile justice system? *Yes NoIf yes, (check all that apply):Arrested Held in juvenile detention Placed on probation Went to courtInvolved for status offense (example: truancy, runaway, ungovernable) OtherOther:Please describe the youth applicant's juvenile justice system involvment Has the youth applicant ever received services from this organization? *YesNoYouth ActivitiesDoes youth applicant participate in any of the following outside of this program (check all that apply): *Religious Activities YMCA Activities Day Camp Sports Big Brothers/Big Sisters Overnight Camp Boys and Girls Club Dance/Theater/Art Boys/Girl Scouts4H OtherOther:Please describeIs the youth applicant currently in counseling? *YesNo Youth Family InformationYouth applicant lives with (check all that apply): *Mother (biological)Step-Mother Adopted MotherFoster MotherGrandmotherFather (biological)Step-Father Adopted FatherFoster FatherGrandfather Sibling(s) Step-Sibling(s)Cousin(s)Aunt(s)Uncle(s) Group & Residential Staff/ProgramOtherOther: *please describeYouth applicant's family member who has struggled, past or present, with the disease of addiction (check all that apply): *Mother (biological)Step-Mother Adopted MotherFoster Mother GrandmotherFather (biological)Step-Father Adopted FatherFoster FatherGrandfatherSibling(s) Step-Sibling(s)Cousin(s)Aunt(s) Uncle(s)Other: Other: *please describePlease indicate the type of substance(s) the youth applicant’s family member(s) has struggled with (check all that apply): *Alcohol Hallucinogens (LSD, PCP, etc.) Stimulants (Cocaine, Meth, Adderall etc.) Marijuana Opioids (Heroin, Fentanyl, Oxycodone etc.) Unknown Prefer Not to SayOtherOther: *please describe Youth applicant has a family member/guardian in the military (past or present): *YesNoPlease indicate all branches that your family has an affiliation with: *ArmyNavy Marine Corps Air Force National Guard Coast Guard Please indicate the status of the family member(s) with military affiliation: *Active ReserveRetired/Veteran Please indicate the family member(s) who were or are in the military (check all that apply): *Mother (biological)Step-Mother Adopted MotherFoster Mother GrandmotherFather (biological)Step-Father Adopted FatherFoster FatherGrandfatherSibling(s) Step-Sibling(s)Cousin(s)Aunt(s) Uncle(s)OtherOther: *please describeYouth Applicant HistoryCamp 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 HealthHas youth applicant or anyone in his/her family experienced mental health issues? *YesNoPlease indicate who has had this experience (check all that apply): *Self MotherFather Sibling (brother/sister)Uncle/Aunt GrandparentCousin Other: Other:please describeAbuse/NeglectHas youth applicant experienced abuse? *YesNoIf yes, please indicate type of abuse (check all that apply): *EmotionalNeglectPhysicalSexualVerbalOtherOther:Please describeFoster Care/Kinship CareHas the youth applicant been in foster or kinship care? *YesNoPlease indicate the youth applicant's status in the foster care system: *Previously in foster or kinship careCurrently in kinship/foster care/group careIn foster care, but in the process of reunifying with their familyGrief/Loss Has the youth applicant experienced grief or loss such as loss due to death, separation or incarceration? *YesNoPlease specify: *Parent/Guardian Contact InformationName: *FirstMiddleLastPrefered Nickname (if any):LayoutDate of Birth: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age: *Gender:FemaleMaleNon-conforming/NonbinaryPrefer to self-describeOther:Please describeAddress: *Address Line 1Address Line 2CityIndianaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone: *Email: *Relationship to applicant: *Emergency ContactsPlease 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:CellHomeEmergency Contact #2 - Name: *Relationship to applicant: *Preferred Phone Number: *Phone Type:CellHomeAdditional Youth InformationPlease 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: *AcknowledgmentCamper: *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: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Submit Want to Get Involved? Aaron’s Place needs people like you to help as mentors, camp facilitators, and volunteers. Find Opportunities With Aarons Place