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Lottery Application for The Aloha Camps

Thank you for your interest in the research study!

To apply to the lottery, please read the Parent Permission Form and have your child read the Youth Assent Form and complete the application below.

If you would like to apply for more than one child, please complete one form per child.

Lottery Application for The Aloha Camps

Parent or Guardian Name*

First

Last
Email*
Phone*
Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Child's Name*

First

Last
Child's full date of birth*
Child's grade in school ('25/'26 school year)*
What school does your child attend?*
My child is available to attend camp from July 21st-August 12th*
- Yes
- No
What are your child's current interests or hobbies?*
What are your child's hopes for the summer? Does your child have any goals for their time with us? What goals and hopes do YOU have for your child this summer?*
Has your child seen a counselor or therapist for an emotional or behavioral issue? If yes, please explain.*
Does your child require assistance during the school day? If yes, please explain.*
Have concerns been expressed about your child's eating habits, impulsivity, or symptoms of anxiety, depression, or self-harm? If yes, please provide brief details.*
What aspects of day-to-day life (e.g. self care, peer pressure, anxiety, friendships, etc.) have been challenging for your child to manage independently in the past?*
What changes, significant events, or life situations has your child experienced that would be helpful for us to understand? Please explain:*
What additional information would be beneficial for us to have in order to help your child enjoy a successful summer?*
Parent Permission Form
I have fully reviewed the Parent Permission Form.
- Yes
- No
Youth Assent Form
My child has fully reviewed the Youth Assent Form and my child agrees to participate in the lottery and survey
- Yes
- No
I hereby give my permission for me and my child to be the subject of the research.
- Yes
- No
Today's Date

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