Culinary Program Summer Camp Application

Camper Information

Prospective Camper Name*

First Middle Last

Gender*

Male

Female

Date of Birth*

MM slash DD slash YYYY

Parent/Guardian Name*

First Middle Last

Email*

Primary Phone*

Preferred Contact Method*

Phone

What county do you live in?*

Anne Arundel

Calvert

Charles

Prince George's

St. Mary's

How did you hear about the Culinary Training Program's Teen Summer Camp?*

Family/Friend/Word of Mouth

Social Media

Community Agency

Other

Disability Information

Please list and describe camper's disabilities, beginning with your primary disability.

Disability #1: What is the disability?*

Disability #1: Date of Onset*

MM slash DD slash YYYY

Disability #1: This disability is a result of:*

Disability #1: How does this disability limit camper's independence?*

Disability #2: What is the disability?

Disability #2: Date of Onset

MM slash DD slash YYYY

Disability #2: This disability is a result of:

Disability #2: How does this disability limit camper's independence?

Disability #3: What is the disability?

Disability #3: Date of Onset

MM slash DD slash YYYY

Disability #3: This disability is a result of:

Disability #3: How does this disability limit camper's independence?

Additional Comments

Education

What is the highest level of education your camper has completed? (Select one)*

No Formal Schooling

Elementary School

Secondary School

Some High School

High School Certificate of Completion

High School Diploma

GED

Name of High School

If applicable.

Are you willing to provide a copy of your camper's most recent IEP and/or 504 Plan? (select one)*

Yes

My Camper doesn't have this documentation.

Please describe why your camper is interested in participating in The Culinary Program’s Teen Summer Camp experience?*

Transportation

Does your student have reliable transportation arranged for each day of camp?*

Yes

Physical Health History

Are you able to stand for at least 2 consecutive hours at a time?*

Yes

If no, please explain.

Please describe any medical conditions (Seizures, Asthma, etc.)*

Do you have food allergies?*

Yes

If yes, please list:

Any other physical conditions or needs that we should be aware of?

Camper Attributes for Success

Personal

Maintains good personal hygiene.*

Yes

Communicates with others and expresses needs clearly.*

Yes

Additional Information:

Handles changes in routine and shows flexibility in fluctuating circumstances.*

Yes

Additional Information:

Social & Emotional

Shows self-regulation and avoids inappropriate outbursts.*

Yes

Additional Information:

Respects self and others.*

Yes

Additional Information:

Works well in a team and individually.*

Yes

Additional Information:

Manages mild stress (e.g. time demands, constructive criticism and coaching)*

Yes

Additional Information:

Cognitive

Functions well in kitchen and classroom learning environments.*

Yes

Additional Information:

Understands basic instructions and carries out those instructions, with low to moderate supervision.*

Yes

Additional Information:

Comprehends written text at a 5th grade level.*

Yes

Additional Information:

Reads and follows basic recipes and directions, including the transfer to action.*

Yes

Additional Information:

Ability to understand and follow safety protocols.*

Yes

Additional Information:

Reasoning sufficient to understand constructive criticism*

Yes

Additional Information:

Vocational

Has the desire and motivation to participate in a pre-vocational educational experience.*

Yes

Willing to learn about and use commercial kitchen equipment such as mixers, stoves, and ovens.*

Yes

Payment

Total Camp Cost: $400

Payment Breakdown:

$100 non-refundable deposit due upon Acceptance

Full Balance Due by June 14

*Limited number of need-based scholarships available upon request

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End Hunger In Calvert County is now doing business as Community Harvest Network. While our name is evolving, our core mission remains the same: Feeding People and Their Futures.

Culinary Summer Camp Application

Camper Information

Disability Information

Education

Transportation

Physical Health History

Camper Attributes for Success

Personal

Social & Emotional

Cognitive

Vocational

Payment

Total Camp Cost: $400

Payment Breakdown: