Teen Application Form Lifesong Wilderness AdventuresCamp Date(Required) MM slash DD slash YYYY Below are a few questions to help us get to know our students a little better. (All student information is confidential and will not be used for any purpose other than providing pertinent information to Lifesong Wilderness Adventures and/or its agents for the sole purpose of determining the suitability of attendance at a Lifesong Wilderness Adventures.) Previous camping experience is not required to attend Teen Camp. Please fill out and return this form via email or USPS @ Mark Wienert, PO BOX 149, Blue River, OR 97413 Contact phone: 530.859.0539.Name of Applicant(Required) First Last Applicant Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Home Phone(Required)Applicant Cell PhoneName of Primary Parent/Guardian(Required) First Last Parent or Guardian e-mail address(Required) Parent/Guardian Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Home Phone(Required)Parent/Guardian Cell PhoneParent/Guardian Work PhoneBirth Date of Applicant(Required) MM slash DD slash YYYY Gender Male Female Grade in School Hobbies/ InterestsOutdoor Camping Experience None Once More than once How Many Times? Where have you camped? Backyard Camp Ground Other Are you prepared to experience minor home sickness while away from home? Yes No Do you have any medical conditions that we need to be aware of?(Required) No Yes Medical ConditionsWould these conditions keep you from participating in strenuous physical activity?(Required) No Yes Explain conditions that might keep you from participating in physical activity:Are you under the care of a physician?(Required) No Yes Explain being under the care of a physician:Are you under the care of a mental health professional?(Required) No Yes Explain being under the care of a mental health professional:Have you been diagnosed with ADD or similar?(Required) No Yes Please list medication(s)Are you on medication of any kind?(Required) No Yes Please list diagnosesIn your own words, what do you expect to experience at teen summer camp?Teens enjoy mastering wilderness skills, exploring the rugged landscape, tracking wildlife and experiencing primitive camping. Some students experience minor home sickness and go through technology withdrawal. Most students overcome this in the first few days and become thoroughly engrossed in their outdoor experience.Mark Wienert is owner and director of Lifesong Wilderness Adventures and is on site for the full duration of camp. As we book a limited number of participants, we urge you to register as early as possible to insure your teens place with us. Our qualified and experienced volunteer staff is hand-picked by Mark. Volunteers and student staff are chosen for their competence, enthusiasm, understanding, and social skills. Our co-ed staff to teen ratio is 1 – 3.At a Lifesong Wilderness Adventures your teen will experience very few of the amenities you would expect of a traditional summer camp.Consent(Required) I agree to the removal policy.I/we hereby certify that the information contained herein is true and accurate. I/we understand that to knowingly furnish false information in the preparation of this form may be cause for removal of participant(s) from camp without a refund after registration is accepted.Signature Method(Required) SIGNATURE BOX TYPE FULL NAME You can choose to either use the live signature box or to simply type out your full name to indicate your legal agreement.Participant SignatureParent/Legal Guardian SignatureParticipant Full Name Parent/Legal Guardian Full Name CAPTCHA
