For more information, visit campedmo.org or call 415.282.6673

To apply please complete an Application, a Health History Form, and a Teacher Recommendation Form. Return these forms, along with payment, to the Community Liaison at your school.

HOW TO APPLY

• To qualify, your family must make under $60K annually.• Each scholarship is for 2 weeks per child, and each child must attend the full two weeks. • Families must pay $50 per week per child for EDMO, and $75 per week per child for EDMO PRO. Price includes daily lunch, morning snack and optional extended day care.

SCHOLARSHIP DETAILS

EDMO (K–4th Grade): As original as you! Mind-blowing science, maker, tech and nature sessions are led by college grads. It’s next generation learning, fueled by old-school values like curiosity, confidence, and kindness.

EDMO PRO (5th–8th Grade): Level Up! Scrap the “kiddy” stuff and get your game face on. Graduate students and industry professionals teach more advanced design, tech, and maker programs. More lab time. Bigger perks. It’s the real deal.

PROGRAM DETAILS

LOCATION: Hall Middle School, 200 Doherty Drive, Larkspur, CADATES: June 26 - Aug 4. Regular camp day runs 9am–3pm.**Scholarship also includes extended day care (AM: 8–9am, PM: 3–6pm)

LOCATION & DATES

CAMP EDMO is a Science, Technology, Maker, Nature, Recreation, & Life Skills summer enrichment program for entering K-8th Graders.

Fullerton FamilyFoundation Scholarship Program2

WEEKS

Date of application:

Camper Info

Last Name:

*If you do not have an email address please write "No Email", and information will be provided by phone or mail.

*If you do not have an email address please write "No Email", and information will be provided by phone or mail.

Home Phone: Cell Phone:

Parent/Guardian #1 InfoFirst Name: Last Name:

Fullerton Family Foundation Scholarship Program

Address (Street, City, State, Zip):

Which is your primary language? (Circle one): English Spanish

Home Phone: Cell Phone:

Address (Street, City, State, Zip):

Camper First Name:

Camper Last Name:Camper Grade in Fall 2017:

Camper Birthdate: Camper School: Camper Gender:

Camper T Shirt Size (all shirts are Youth Sized): XS S M L XL Will your child require an aid at camp?:

Which is your primary language? (Circle one): English Spanish

Thank you for your interest in Camp EDMO's Marin Scholarship Program funded by the Fullerton Family Foundation! This program is for families with a gross annual household income under $60K who can pay $50 per week for CAMP EDMO (entering K-4th) and $75 per week for CAMP EDMO PRO (entering 5th - 8th). Scholarships are for 2 weeks, and each child must attend the full two weeks.

This is a first come, first serve program with limited spots available. Please complete this application, the attached Health History Form, and the attached Teacher Recommendation form. Return all forms, with payment for two weeks per child, to the Community Liaison at your school before April 1, 2017.

Parent/Guardian #2 Info

Relationship to Camper: Email Address*:

First Name:

Relationship to Camper: Email Address*:

(Continued on Back)Edenture More

2295 Palou Ave, San Francisco, CA, 94124www.campedmo.org

Have any of your children attended CAMP EDMO or EDMO PRO before? Yes / No

How much is your annual total household income (before taxes)?:

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☐ ☐* No camp on Tuesday 7/4

Yes, I will need extended AM care from 8AM - 9AM ☐

Yes, I will need extended PM care from 3PM - 6PM ☐

How do you see this experience benefitting your child?

Family Information and Scholarship Details

DateEntering K-4th graders

Thanks for applying, hope to see you at camp!

Do you qualify for the reduced lunch program at your school? Yes / No

Maker/Science: Makeropolis

Tech: Minecraft: Mod Maker

Tech: Lego Animation

Tech: Minecraft: EDMOtopia

Tech: Minecraft: Mod Maker

Tech: Lego Animation

Tech: Minecraft: EDMOtopia

The regular camp day runs from 9AM - 3PM. This scholarships includes optional extended day care for no extra charge. Please indicate whether you would partake in this service either in the morning or the afternoon:

Please CHECK ALL SESSIONS that you would be willing and able to attend: **Having multiple date options increases the chance of receiving a scholarship. You will be assigned to 2 weeks of camp based on the availability you indicate here.

7/31 - 8/4

6/26 - 6/30

7/3 - 7/7

7/10 - 7/14

7/17 - 7/21

Maker/Science: DIY da Vinci

Maker/Science: Power Up

Maker/Science: Makeropolis

Maker/Science: DIY da Vinci

EDMO Option 1 EDMO Option 2

7/24 - 7/28 Maker/Science: Power Up

7/17 - 7/21

7/31 - 8/4

EDMO PRO

7/24 - 7/28

Maker: Smile Mob Challenge

Entering 5th - 8th Graders

Date

6/26 - 6/30

7/3 - 7/7

7/10 - 7/14

Maker: Mobstacle Course

Maker: Tech Styles

Maker: WordPress Web Design

Maker: Smile Mob Challenge

Maker: Mobstacle Course Tech: Game Coder

Tech: Minecraft: Mod Coder

Tech: Game Coder

Tech: Minecraft: PROtopia

Tech: App Inventor

Tech: Minecraft: Mod Coder

Edenture More2295 Palou Ave, San Francisco, CA, 94124

www.campedmo.org

CAMP EDMO 2295 Palou Ave, San Francisco, CA, 94124

415.282.6673 www.campedmo.org

HealthHistoryForm

Thefollowinginformationmustbe completedprior toattendingcamp.I.CamperInformation

FirstName:

LastName:

Location__________________________

II.EmergencyContactInformation1(Pleasedo NOT listparents/guardians—theywill be contactedfirst)

Name: Relationship: Home Phone #:

III.EmergencyContactInformation2

Work#:

Cell#:

Name: Relationship:

Home Phone #:

Work#:

Cell#:

IV.AuthorizedCheck-out/Pickup List(Pleasedo not listparents/guardians)

Thefollowingpersonsare authorizedto pickup your childfrom EdventureMore at any time. Allpersonslistedwillbeaskedto

providephotoidentificationat the time of pickup.

Name1: Relationship: Name2:

Relationship:

Name3: Relationship:

Isthecamperallowedtosignthemselvesinandoutofcamp?________Yes________No

V.InsuranceInformation

Isthe campercoveredbymedical/hospitalinsurance? Yes NoIfso,pleaseindicatecarrierorplannameandpolicynumber:

VI.MedicalInformation

Allergies: Yes NoIfyes,pleaselistallknownallergies(e.g. peanuts,beestings,hay fever .etc)Allergy1: Reaction/symptom: Allergy2: Reaction/Symptom:

VII.Medications(ifnone takenregularly,checkbox and skip toVIII.) NOmedicationstakenregularlyIfmedicationswillbe takento camp,pleaselistthembelow.Keep itinthe original packaging/bottlethatidentifiestheprescribingphysician,the nameof the medication,the dosage,andthe frequencyof administration.Medication1: DosageandFrequency: Reasonformedication: Medication2: DosageandFrequency: Reasonformedication:

CAMP EDMO 2295 Palou Ave, San Francisco, CA, 94124

415.282.6673 www.campedmo.org

HealthHistoryForm

VIII.Pleasedescribeany other healthrelatedissuesthe EdventureMore stafformedicalpersonnelshouldknowaboutthiscamperwhenadministeringcare:

Pleasereadthefollowingwaivercarefullyandsignbelow:

• Explanation:EdventureMoreisayear-round501(c)(3)non-profitenrichmentorganization.Wetakeeveryprecautiontoensuretheauthorizationgrantedonthisformwillneverneedtobeused.Forthesafetyofthechildren,however,soundmedicalpracticecallsforthisauthorization.Theauthorizationgrantedbythisformwillbeusedonlywhenabsolutelynecessary.Wewillmakeeveryattempttofirstcontacttheparent/guardiantomakemedicalcaredecisionsunlessthesituationcallsforimmediateprofessionalmedicalcare.ThisauthorizationwillbekeptonfilewithEdventureMoreandtheinformationrecordedherewillbepresentonsiteduringallEdventureprograms(summercamps,afterschool,inclass,etc.)forwhichyouhaveregistered.

• Attestation:IattestthatIamover18yearsofageandIwarrantthatIhavelegalauthoritytoexecutethisagreementonbehalfofmychildorward.IattestthatmychildorwardisphysicallyfitandpreparedforEdventureMoreeventsandallrelatedactivities.IgrantfullpermissionforEdventureMore,itsnonprofitpartneragencies,anditsofficersanddirectors,partners,employees,agents,andvolunteers(“Releasees”)forthefollowingauthorizations.

• MedicalAuthorization:IherebygivepermissionformychildorwardtotakepartinallactivitiesledbyEdventureMorestaff.Incaseanemergencyhappensatanypointbetweensigninandsignouttheprogram,Iherebyauthorizeanyofthestaff,employees,agentsandrepresentativesofEdventureMoretoprovidefor,approve,andauthorizeformychildorward,anyhealthcareatanyhospital,emergencyroom,doctor'sofficeorotherinstitution,employanyphysicians,dentists,nursesorotherpersonwhoseservicesmaybeneededforsuchhealthcare,reviewandifnecessarydisclosethecontentsofanymedicalrecords,executeanyconsentformrequiredbymedical,dentalorotherhealthauthoritiesincidenttotheprovisionofmedical,surgical,ordentalcaretothechild.Healthcareshallinclude,butnotbelimitedtotheadministrationofanesthesia,x-ray,examination,performanceofoperations,diagnosticandotherprocedures.IherebyfurtherauthorizeemergencytransportationbyeitherEdventureMorepersonnelorifnecessarybyambulanceorotheremergencyvehicle.Ifthereisnomedicalemergency,theEdventureMorestaffwillfirstusereasonableeffortstocontacttheparent(s)and/orguardian(s)beforeadministeringorauthorizinganytreatment.

• Photo/VideoRelease:IherebyauthorizeEdventureMoreanditsaffiliates,successorsandassigns,todisplay,publiclyperform,exhibit,transmit,broadcast,reproduce,record,photograph,digitize,modify,alter,edit,adapt,createderivativeworks,exploit,sell,rent,license,otherwiseuseandpermitotherstouse,reproduce,and/orpublishanyphotographs,video,and/oraudiothatmaypertaintomychildorward,includingmychildorward'simage,likenessand/orvoicewithoutfurthercompensationorpermission.Iunderstandthatthismaterialand/orrelatedquotationsmaybeusedinvariouspublications,publicaffairsreleases,recruitmentmaterials,promotions,accounts,broadcastpublicserviceadvertising(PSAs)orforotherrelatedendeavors.ThismaterialmayalsoappearonEdventureMore'soraprojectsponsor'sInternetWebPage.Thisauthorizationiscontinuousandmayonlybewithdrawnbymyspecificrescissionofthisauthorization.Consequently,EdventureMoreoraprojectsponsormaypublishmaterials,usemyname,photograph,and/ormakereferencetomeinanymannerthattheCorporationorprojectsponsordeemsappropriateinordertopromote/publicizeserviceopportunities.Iherebywaivemyrightofpublicityinconnectionwithsuchuses.

CAMP EDMO 2295 Palou Ave, San Francisco, CA, 94124

415.282.6673 www.campedmo.org

HealthHistoryForm

• Off-SiteAuthorization(Ifapplicable):Iunderstandthatoccasionallychildrenunderthesupervisionofstaffmayleavetheprogramcampustonearbyparksandrecreationfacilities.Pleasereviewwebsite,welcomepackete-mail,and/orcalltoverifyifyourEdventureMoreprogramhasspecificoff-sitelocationinformationandroutes.

• CampEdmoParkProgramFieldTrips:IfmychildorwardisenrolledinaCampEdmoParkProgramthemedweekandisinthecorrespondingagegroup(typicallyentering2nd-4thgradewithnotedexceptionsatcertainsites),he/shehaspermissiontoboardacharteredbusorothervehicledesignatedbyEdventureMorepersonnelinordertotraveltothedesignatedoff-sitefieldtriplocation(s)eachweek.IfIshouldchangemymindandrevokepermissionforaparticularoff-sitefieldtrip(s),IunderstandthatImustcontacttheEdventureMorehomeofficeinwritingorspeaktosomeoneinpersonat(415)282-6673beforethefieldtripdate,andschedulealternatecareformychildorwardthatday.Additionalinformationregardingoff-sitelocationsand/orroutes,maybefoundontheEdventureMorewebsite,welcomepackete-mail,orbycallingtheEdventureMorehomeoffice.

• Releases:Inconnectionwithmychildorward’svoluntaryinvolvementinactivitiesforEdventureMore,Iherebyagree,formeandmychildorward,ourheirs,assigns,executorsandadministratorstoreleaseanddischargeReleaseesfromallclaims,demandsandactionsforinjuriesordeathsustainedtomychildorwardand/ordamagetoordestruction,lossortheftofmypropertyofmychildorwardandtothepropertyofothersasaresultofmychildorward’sinvolvementinsuchactivities,whetherornotresultingfrommychildorward’snegligenceorthenegligenceofanyotherindividual,orfromaccidentswithoutnegligence,orfromtheintentionalactionsofotherindividuals,andIagreetoreleaseandholdReleaseesharmlessfromanycauseoraction,claimorsuitarisingtherefrom.

• Indemnity:Iwilldefend,indemnify,holdharmlessandreimburseEdventureMorefromandforalldamages,losses,costs,orexpenses(includinglegalfees)incurredbyEdventureMoreorpaidbythemtoanyperson(includingmeormyinsurers)inrespectofanyaccident,injury(includingdeath),loss,orpropertydamage,howevercausedresultingfrom,arisingoutof,orotherwiseinconnectionwithmychildorward’sparticipationinsuchrelatedeventsandactivities.IwillreimburseEdventureMoreifanyonemakesaclaimagainstEdventureMoreinconnectionwithmychildorward’sparticipationinsuchrelatedeventsandactivites,including,withoutlimitation,anyaccidentmychildorwardmaybeinvolvedin,oranyinjury,loss,damagetomychildorward,me,otherparties,orpropertyhowevercaused.

• Acknowledgement:Theaboveauthorizationsshallbebindinguponandenforceableagainstme,mypersonalrepresentatives,spouse,assigns,heirsandnextofkinwithoutlimitation.Itismydesireandintentthatthewords,terms,provisions,covenants,andremediescontainedintheaboveauthorizationsshallbeenforceabletothefullestextentpermittedbyapplicablelaw.Ifanyportionoftheaboveauthorizationsareheldinvalid,theremaindershallnotbeaffectedandshallcontinueinfulllegalforceandeffect.Iattestthatmychildorward’sattendanceandinvolvementinsuchactivitiesisfullyvoluntary,thatIamallowingmychildorwardtoparticipateathisorherownrisk,andthatIhavereadtheforegoingtermsandconditionsofthisdocument.Iamherebyagreeingtoallstipulationsasstatedabove.

Signatureof parentorguardian Date

Date of application:

School Name: Teacher Name:

Teacher Phone: Teacher Email:

Student Name:

Relative to Grade level, how would you rate this student on the following items:

(Your ratings will not affect a student's chance of receiving a scholarship)

Please circle your answer:

Below grade level At grade level Above grade level

Below grade level At grade level Above grade level

Below grade level At grade level Above grade level

Below grade level At grade level Above grade level

Below grade level At grade level Above grade level

Below grade level At grade level Above grade level

Below grade level At grade level Above grade level

Below grade level At grade level Above grade level

Below grade level At grade level Above grade level

Is there anything else you would like to tell us about this student?

Do you receive our quarterly newsletter for Teachers?☐☐☐☐ Yes! I am familiar with your Summer Camp programs. ☐☐☐☐ Yes! I am already on the list.☐☐☐☐ Yes! I am familiar with your School Year programs. ☐☐☐☐ No thank you.☐☐☐☐ Yes! I am familiar with your Giving program. ☐☐☐☐☐☐☐☐ No, this is the first I’ve heard of them.

Feel free to contact us with any questions, and thank you for the wonderful work you do with families each year!

Date

Science Enthusiasm:

Ability to communicate emotions:

Are you familiar with CAMP EDMO's programs? Please check all that

apply.

Teacher Signature

Teacher Recommendation Form: CAMP EDMO Financial Aid or Scholarship

Not yet, but please put me on the list.(Please make

sure you have provided your email address above)

This form is to be completed by the teacher of the child applying for financial aid or a scholarship for CAMP EDMO.

The information gathered in this form will be kept confidential. Information gathered here may be anonymized and used

in the future to help us assess the impact of our programs. Please fill this form out at your earliest convenience and

return to us at the address or fax on the bottom of this page.

Reading Skills:

At Edventure More, a 501(c)(3) non-profit, we create high-quality, high-access STEM and SEL programs that foster

intellectual, social, emotional, and physical intelligence in all children. Learn more about the camps that your student is

interested in attending at campedmo.org.

Teacher Information

Student Information

Ability to empathize with others:

Ability to make responsible decisions:

Collaboration Skills:

Problem Solving Skills:

Initiative and self-direction:

Science Proficiency:

www.campedmo.org

2295 Palou Ave, San Francisco, CA, 94124

Phone: 415.282.6673 Fax: 415 449 6161