Camp Mariposa Youth Application

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Application and Enrollment Process

Camp Mariposa is a year-round addiction prevention and mentoring program for youth affected by the substance use disorder of a family member. All youth and mentors make a one-year commitment to the program by attending at least four camps and additional activities. 

Camp Mariposa has been providing services for youth and families for over fifteen years. We recognize some questions in the application may be sensitive information for you to share. The information gathered allows us to develop a program that will benefit all youth and gather important demographic information.

If you have questions or concerns about the application, please contact your local Camp Mariposa Program Director.

Please read the following instructions before completing the application:

The youth application will take approximately 15-30 minutes to complete. As part of the online process, you will complete three forms.

 Fields marked with a * are required.

Once you fill out your online application, you will receive a verification email. The email will include details on the next steps to finalize and submit your application. If the email is not in your inbox, please check your Spam folder.

If you would like to enroll or re-enroll multiple youth, please submit a separate online application for each youth.

Submission of the online application does not guarantee your child(ren) will be enrolled in Camp Mariposa. After your application is processed, a member of the Camp Mariposa Team will be in touch with you to discuss the next steps.

For more information on how we collect, use, share and otherwise process information about you and your child(ren), please see our Privacy Policy here.

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Parent/Guardian Contact Information

First Name:

Last Name:

MI:

Date of Birth (MM/DD/YYYY):

Age:

Preferred Name/Nickname:

Gender:

Gender Self-Description

Pronouns

Pronoun Self-description

Does parent/guardian have the same address as the youth applicant?

Yes

No

Street Address:

Apartment/Unit Number:

City:

State:

Zip Code:

Phone Number:

Email:

Relationship to youth applicant:

Relationship to youth applicant other detail:

Emergency Contacts

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

Emergency Contact 1

First Name:

Last Name:

Preferred Phone Number:

Phone Type:

Relationship to youth applicant:

Emergency Contact 2

First Name:

Last Name:

Preferred Phone Number:

Phone Type:

Relationship to youth applicant:

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Additional Youth Information

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

Please list any hobbies or interests the youth applicant has:

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

Acknowledgement

I understand Camp Mariposa is a yearlong program. I will make every effort to ensure my youth applicant attends each camp and a majority of the social activities that will be held in the coming year.

I understand submission of this online application does not guarantee my youth applicant will be enrolled or re-enrolled in Camp Mariposa.

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As part of the Camp Mariposa enrollment process, we require you to sign our Consent and Release. Among other things, the Consent and Release describes what we will and will not be responsible to you for, the kinds of information we might collect about you and/or any child under your care, and what we can do with this information. Here are some important highlights:

We might collect information about you and/or children under your care in connection with your and their participation in Camp Mariposa, including statements and videos, photos, and audio recordings of you or participating children under your care.

We can use this information, whether now or at any time in the future, for any legal purpose, including to promote Camp Mariposa or share how Camp Mariposa supports youth and families who are grieving (for example, in a flyer, social media post, or video advertisement).

The Consent and Release confirms that you understand that participating in Camp Mariposa might come with certain risks (for example, you or children under your care could get sick, injured, or experience other harm) and you are willing and able to take on these risks on behalf of yourself and participating children under your care.

Unless you opt out of our communications, Eluna can contact you with additional resources, information, news, updates, and other communications using the information you provide to us.

If you have questions about the Consent and Release, please contact the Camp/Program Director.

This summary is not a legal document and is not part of the Consent and Release. It is provided only for your convenience, is not exhaustive, and does not replace reading the Consent and Release. If anything in this summary conflicts with the Consent and Release, the terms of the Consent and Release will control.

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CAMP MARIPOSA® PHOTO, PUBLICITY AND LIABILITY CONSENT AND RELEASE

I,

(print name of Parent/Guardian/Caretaker or Adult Participant),

understand that Eluna desires to use certain audio or visual works in which I and/or my child or any child under my care, including without limitation to individuals identified in the “Youth Participant Information” section below (collectively, “Children”) might appear (e.g. video or photographs) and certain information about my Children or me, in connection with my participation, or the participation of my Children in Camp Mariposa® as a camper, junior counselor, alumni, youth family member, employee, volunteer or visitor. I understand these audio or visual works may be used to advertise, promote, distribute, market, research, obtain funding for and sell various services, including Camp Mariposa and its related activities. I also understand that, as part of my or my Children’s participation in Camp Mariposa, I or my Children may be exposed to or experience Harm (defined below), including as a result of infection by COVID-19 (also known as SARS-CoV-2 or the coronavirus) (“COVID 19”). By this Consent and Release Agreement (“Consent and Release”), I hereby grant certain rights to Eluna and release Eluna from certain liabilities, on behalf of myself (if I am a camper, employee, volunteer or visitor) or on behalf of my Children (if I am the parent, guardian, or caretaker of a minor camper, junior counselor, alumni or youth family member, employee, volunteer or visitor). This Consent and Release confirms my Children’s and my grant of rights and our agreement is as follows:

1. Grant of Rights.

For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I, on behalf of myself and my Children, hereby grant to Eluna and its directors, officers, employees, agents, representatives, contractors, successors, and assigns the perpetual, irrevocable, royalty-free, non-exclusive, worldwide, sublicensable right and license to: (a) use, edit, reproduce, modify, portray, publish, copy, distribute, create derivative works from, publicly perform and display without restriction all or portions of my or my Children's identity and my or my Children’s experience at Camp Mariposa, including without limitation my or my Children’s name, fictional names (if any), voice, signature, photograph, words, image, personality or other likeness of me or my Children, and any audio and video recordings of me or my Children or remarks and statements made by me or my Children (“Images and Remarks”); and, (b) create other materials or copyright-protected works using or incorporating my or my Children's Images and Remarks in any form or manner, including in any electronic or non-electronic medium now known or later devised, in connection with Camp Mariposa for advertising, distribution, marketing, promotion, publicity, research, reporting or any other lawful purpose (“Promotional Materials”). I understand that this Consent and Release will cover all of my or my Children’s future participation at any Camp Mariposa activities.

I waive any of my or my Children's right to own, inspect, approve or receive any payment or attribution with respect to any works or Promotional Materials using my or my Children's Images and Remarks, any accompanying written copy or printed matter, or the use to which it is applied. I understand and agree that the Images and Remarks, and Promotional Materials containing or based on my or my Children's Images and Remarks may be used without any restriction as to changes or alterations, and may be modified, used in derivative works, distorted, included in composites or otherwise used in unexpected contexts, manners, or forms, or may not be used at all, and I grant Eluna all necessary rights to do the foregoing. To the extent moral rights in my or my Children's Images and Remarks or any Promotional Materials may not lawfully be waived, I hereby agree not to bring any actions or claims against Eluna therefor.

2. Contact. Unless I opt out below, I agree to receive information/news/updates and other communications in hard copy, via electronic delivery, via telephone and other means from Eluna. I hereby consent to collection and disclosure of my mailing address, email address and phone number to Eluna for such purposes, unless I opt out below.

3. Release.

I, on behalf of myself and my Children, hereby fully and forever release, discharge, and agree to indemnify, defend and hold harmless Eluna and its directors, officers, employees and advisors (collectively, the “Released Parties”) from any and all claims, demands, causes of action, damages (including without limitation direct, indirect, incidental, consequential, special or punitive damages), losses, expenses and liabilities (whether under contractor, warranty or tort, including negligence (whether active, passive, or imputed)) relating to any claim that my Children or I may have, now or in the future, based on: (a) any usage or adaptation, whether intentional or unintentional, of my or my Children's Images and Remarks or portions thereof, or works or materials derived therefrom including, but not limited to, claims for libel, defamation, invasion of privacy or rights of publicity, infringement or violation of moral rights or any other right arising out of, or relating to, any use of my or my Children's Images and Remarks, including by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, or based upon any failure or omission to make use thereof; or (b) death, personal injury, property damage, pecuniary or other loss, damage, cost or expense (collectively, “Harm”) that may be suffered by my Children, me or any third party as a result of, or in connection with, my or my Children's participation in, volunteering for, or employment by Camp Mariposa, including any Harm or infection caused by exposure to COVID-19 that I or my Children may experience by attending Camp Mariposa activities. Camp Mariposa and Eluna cannot guarantee that you/you and your Children will not become infected with COVID-19. Further, attending Camp Mariposa activities could increase your risk and your Children’s risk of contracting COVID-19. By signing this Consent and Release, I understand the contagious nature of COVID-19 and voluntarily assume the risk that I or my Children and I may be exposed to or infected by COVID-19 by attending Camp Mariposa activities, and that such exposure or infection may result in personal injury, illness, permanent disability, or death. I understand that the risk of becoming exposed to or infected by COVID-19 at Camp Mariposa activities may result from the actions, omissions, or negligence of myself and/or others, including, but not limited to, Eluna, Camp Mariposa and their respective directors, officers, employees, agents, volunteers, or program participants and their families. I understand that this waiver will cover all of my or my Children’s future participation at any Camp Mariposa activities. I voluntarily assume all of the foregoing risks and accept sole responsibility for any illness or injury to myself/to myself and my Children, including, but not limited to, personal injury, disability, and death, damage, loss, claim, liability, or expense, of any kind, that I or my Children may experience or incur in connection with my or my Children’s attendance at or participation in Camp Mariposa activities. I AGREE TO INDEMNIFY AND HOLD HARMLESS EACH OF THE RELEASED PARTIES FROM AND AGAINST ANY AND ALL CLAIMS, COSTS, LOSSES, DAMAGES AND EXPENSES (INCLUDING REASONABLE ATTORNEYS' FEES) INCURRED BY ANY RELEASED PARTY ARISING OUT OF OR IN CONNECTION WITH ANY HARM OR RELEASED CLAIMS. If any provision of this Release is held to be invalid or unenforceable, then that provision shall be severed, and all remaining provisions shall be given full force and effect.

4. Representations and Warranties. I represent and warrant that: (a) my or my Children’s involvement or participation in Camp Mariposa is voluntary, (b) I understand that there is a risk of danger, bodily harm, injury, emotional stress, or death as a result of my or my Children’s participation in, volunteering for, or employment by Camp Mariposa, (c) I further understand that there is the potential for risks and dangers that may not be obvious or reasonably foreseeable at this time related to my or my Children’s participation in, volunteering for, or employment by Camp Mariposa, and (d) I voluntarily, on behalf of myself or my Children, assume the risks, including, but not limited to, those outlined in items (b) and (c) above. I further represent and warrant that I have the power, capacity and authority to grant the rights to Eluna herein granted, that this Consent and Release constitutes my or my Children's legal and binding obligation enforceable in accordance with its terms and that the grants of rights or any portions thereof will not conflict with any similar grants of rights agreements I or my Children have made.

5. Binding Agreement. This Consent and Release expresses the entire understanding between Eluna, me and my Children, and supersedes any prior agreements and discussions between us with respect to the subject matter of this Consent and Release. In granting the rights herein, neither I nor my Children have been coerced or induced to do so by any representations or assurances by Eluna or its agents or representatives. This Consent and Release may be amended only by written instrument signed by Eluna and me. The provisions hereof shall be binding upon me, my Children and my heirs, representatives, executors, administrators, and successors. Eluna may, in its sole discretion, assign or transfer some or all of this Consent and Release.

6. Governing Law. This Consent and Release will be governed by the laws of the State of Pennsylvania, without regard to its choice of law principles. The parties hereby submit to the exclusive venue and jurisdiction of the state and federal courts of Philadelphia County, Pennsylvania and waive any objection thereto (irrespective of whether the individual signing this Consent and Release changes his or her state of residence).

7. Severability. If any provision of this Consent and Release Agreement is found to be unenforceable in any respect by a court of competent jurisdiction, this Consent and Release Agreement will nonetheless be enforced to the maximum extent to which it is found to be legally enforceable.

BY SIGNATURE BELOW, I AGREE AND ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD, AND ACCEPTED THIS CONSENT AND RELEASE; THAT THE PROVISIONS CONTAINED HEREIN REPRESENT AN AGREED ALLOCATION OF RISKS WHICH ELUNA IS RELYING UPON; THAT I HAVE SIGNED THIS CONSENT AND RELEASE VOLUNTARILY AND OF MY OWN FREE WILL; AND THAT I HAVE HAD AMPLE OPPORTUNITY TO ASK QUESTIONS REGARDING THE TERMS AND CONDITIONS OF THIS CONSENT AND RELEASE.

Agreed and Accepted: Participant or Parent/Guardian/Caretaker of Participant

Participant is:

Youth Camper

Jr. Counselor/Alumni/Teen

Youth First and Last Name

Youth Date of Birth

MM/DD/YYYY

Parent/Guardian First and Last Name

Parent/Guardian Date of Birth

MM/DD/YYYY

Date

I hereby opt out of receiving non-essential Eluna communications, such as newsletters and updates

Additional details, use only as directed:

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Camp Mariposa Evaluation of Informed Consent for Parents and Guardians

Important Notice: Please read this consent document before proceeding.

Purpose:
Camp Mariposa collects information on participants for organizational, research, and evaluation purposes. Through this effort, we hope to continuously improve the Camp Mariposa program. By proceeding and signing the bottom of this page, you have agreed for you and your youth to participate. This program evaluation is being conducted by Camp Mariposa and Eluna, in conjunction with researchers and Camp Mariposa funders. We appreciate your participation.

Risks and Benefits:
The Youth Application, Evaluation Survey, and Youth Questionnaire include items regarding family history, substance use, juvenile justice involvement, peer relationships, mentor relationships, education, and quality of life. If any of these topics make you or your youth uncomfortable, or you do not care to answer, you or your youth may choose not to answer. The collection of this information and the subsequent evaluation process pose minimal risk as Camp Mariposa ensures confidentiality of your information.

Right to Privacy:

All forms and materials will be maintained by Camp Mariposa staff, and any data shared for research or evaluation purposes will be made anonymous to protect participant confidentiality. Identifiable information collected during the study will be removed, and de-identified information be used for future research studies or distributed to another investigator for future research studies without additional informed consent from participants or legally authorized representative. The results of any research or evaluation may be released to Camp Mariposa management, Eluna, affiliates and funders. If the results of any study are shared or published, the privacy of camp participants and their families will be protected, and individuals will not be identified in any way.

Right to Participate or Withdraw:
This notice is distributed to all Camp Mariposa campers and their parents/guardians. Participation is completely voluntary, and you or your youth may request to withdraw consent (verbally or in writing), choose not to answer any question on our forms, and/or ask questions at any time. You and your youth’s relationship with Eluna, Camp Mariposa, and any research or funding entities supporting this work will not be affected if you or your youth chose to not take part in the study or change your mind later. There is no incentive for participating at this time other than knowing you are helping us develop our program to help future campers and their families.

Consent:
Below we request the consent of camper parents/guardians. Your signature means that you have read this form in its entirety, comprehend the consent, and are willing to participate in sharing your and your youth’s information for program evaluation and research purposes.

I have read the CM Evaluation Notice of Informed Consent and I:

Provide permission for my youth to participate in the evaluation study. I understand all forms and materials will be maintained by Camp Mariposa staff, and any data shared for research or evaluation purposes will be made anonymous to protect confidentiality. Do not want my youth to participate in the evaluation study.

Parent/Guardian Printed First & Last Name for Consent:

Date:

For any questions about this form or the research and evaluation project, please contact: Brian J. Maus, MA, LMFT, Director of Addiction Prevention and Mentoring Programs at brianmaus@elunanetwork.org or 267-563-7462

I hereby certify that the information given on this application is factual and complete. I give my permission for any necessary verification. I release from liability any person and/or this organization giving, receiving, or utilizing such information in making decisions regarding my child/youth’s enrollment in Camp Mariposa.

CM Director/Staff	CM Parent/Caregiver	Friend
School	Social Worker/Case Manager	Therapist
Social Media (Facebook, Instagram, etc.)	Eluna Website	Web-based or Google search
MENTOR Connector	Other

African-American/Black	American Indian/Native American	Asian
Hispanic/Latinx	Pacific Islander	White/Caucasian
Multi-Racial	Other Race/Ethnicity

African-American/Black	American Indian/Native American	Asian
Hispanic/Latinx	Pacific Islander	White/Caucasian
Other Race/Ethnicity

Arrested	Held in juvenile detention
Placed on probation	Went to court
Involved for status offence (ex: truancy, runaway, ungovernable)	Other

Religious Activities	Sports	Boys and Girls Clubs
Boys/Girls Scouts	YMCA Activities	Big Brothers/Big Sisters
Dance/Theater/Art	4H	Day Camp
Overnight Camp	Other

Mother (biological)	Father (biological)	Step-Mother	Step-Father
Adopted Mother	Adopted Father	Foster Mother	Foster Father
Grandmother	Grandfather	Sibling(s)	Step-Sibling(s)
Aunt(s)	Uncle(s)	Cousin(s)	Other
Youth & Residential Program Staff

Alcohol	Hallucinogens (LSD, PCP, etc.)	Stimulants (Cocaine, Meth, Adderall, etc.)
Marijuana	Opioids (Heroin, Fentanyl, Oxycodone, etc.)	Other
Unknown	Prefer not to say

Army	Navy	Marine Corps	Air Force
National Guard	Coast Guard	Space Force

Youth Applicant	Mother	Father	Grandparent
Sibling	Aunt/Uncle	Cousin	Other

Deceased - Parent	Incarcerated - Parent	Separated - Parent
Deceased - Sibling	Incarcerated - Sibling	Separated - Sibling
Deceased - Grandparent	Incarcerated - Grandparent	Separated - Grandparent
Deceased - Other Family Member	Incarcerated - Other Family Member	Separated - Other Family Member

Emotional	Neglect	Physical
Sexual	Verbal	Other