Summer Camp Registration - Variety St. Louis

Register for Summer Adventure Camp 2025

Registration for Summer Adventure Camp will open on Monday, January 13, 2025. When camp registration is full, a waiting list will be open.

This free day camp experience is for kids and teens with disabilities living in the 30 Missouri and Illinois counties Variety St. Louis serves.

Adventure Camp is available to children and teens ages 4 – 20. Campers are split into groups based on age to enjoy activities geared more toward their interests.

The location of camp changes daily to accommodate different activities and adventures, but each is located within the St. Louis region. This year’s Camp schedule is below – all ages are invited to attend ONE week.

Week 1: June 2 – 6
Week 2: June 9 – 13
Week 3: June 16 – 20
Week 4: June 23 – 27
Week 5: July 7 – 11
Week 6: July 14 – 18

Requirements:

A $100 deposit: accepting personal checks only. Check will not be deposited unless your camper does not show up for their week of camp. (Please mail or deliver to Variety’s office at 11840 Westline Industrial Drive, Suite 220, St. Louis, MO 63146.)
Medical Records: Submitted via US mail, fax, or email (send to Amy Birnstill or Janette Coleman)
- Immunization records.
- A physical less than a year old.
Both the deposit and medical records must be submitted by May 1, 2025 for camper to be eligible to attend camp. No exceptions.

All required documents must be received by May 1, 2025 to complete your registration. Your assigned week of camp is contingent on submission of all required documentation.

Questions? Contact Amy Birnstill at Amy@VarietySTL.org or at 314-720-7719.

Camp Registration - Summer

*Required field

This year, each child may attend camp only one week. Preferred choices will be considered but not guaranteed.

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Preferred number of weeks to attend camp(Required)

Please select all the weeks your camper is available.(Required)

Week 1: June 2 - 6

Week 2: June 9 - 13

Week 3: June 16 - 20

Week 4: June 23 - 27

Week 5: July 7 - 11

Week 6: July 14 - 18

From the weeks your camper is available, which is your first choice?(Required)

From the weeks your camper is available, which is your second choice?(Required)

From the weeks your camper is available, which is your third choice?(Required)

Please understand camper placement is a complex process, but our staff will try to accommodate as many first and second choices as possible.

Camper Information

Camper Name(Required)

First Last

Camper Date of Birth(Required)

T-Shirt Size

My child identifies as(Required)

What is your child's race/ethnicity?(Required)

Is this your child's first time at Variety Camp?(Required)

Yes

Primary Diagnosis (No abbreviations)(Required)

Secondary Diagnosis (No abbreviations)

Parent/Guardian Information

Parent/Guardian Relationship Type

Parent/Guardian Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

County(Required)

Primary Phone (number you wish to be called during camp)(Required)

Who does the primary phone number belong to?

Secondary Phone

Who does the secondary phone number belong to?

Email(Required)

Annual Household Income(Required)

Variety collects household income data for reporting purposes only. Your response will not influence your application for Recreation and/or Performing Arts programming.

Do you need to add information for an additional parent?(Required)

Yes

Parent/Guardian 2 Relationship Type

Parent/Guardian 2 Name

First Last

Address 2

Same as previous

Street Address City State / Province / Region ZIP / Postal Code

County

Primary Phone

Secondary Phone

Additional Health Information

Child's Medical History(Required)

Enter any additional health related information that will assist camp staff in helping your child have a successful camp experience.

What are your child's communication abilities? (check all that apply)(Required)

My child speaks and is understood by others

My child is able to maintain a two-way conversation

My child communicates through Sign Language

My child communicates through an Augmentative Speech Device

My child communicates through their iPad

My child communicates through gestures

My child is nonverbal or has limited conversational abilities

My child has no means of communication

Transportation support

My child is able to load and unload on a typical bus

My child is able to transfer from their chair into a typical bus seat

My child requires accessible transportation (wheelchair compatible bus)

What type of support does your child need during typical camp activities?(Required)

Two counselors to one camper

One counselor to one camper

One counselor to two campers

One counselor to three campers

What type of support does your child need during swimming, specifically?(Required)

Two counselors to one camper

One counselor to one camper

One counselor to two campers

One counselor to three campers

List any allergies your child has.(Required)

(e.g. peanuts, bee stings, latex)

Please provide tips to communicate with your child.(Required)

My child eats... (check all that apply)

Independently

Hand-over-hand assistance

Tube Fed

Only small soft foods

Pured foods

(check all that apply)

Toileting needs:(Required)

Tricks for happy toileting experiences:

(i.e. how you get your child to lay down, or sit on the toilet, frequency of bathroom breaks, etc.)

Preferences

Preferred Variety Counselor

Preferred Variety Friend

If you wish your child to be paired with a certain child we will try to accommodate your request. This is to enhance socialization. Both friends must choose one another.

General Information

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School or program your child attends(Required)

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School District(Required)

Does your child have a behavior plan in place at school?(Required)

Yes

Having a behavior plan in no way disqualifies any child from participation in Variety Camp. If your child does have a behavior plan, please fax or mail a copy to Variety. Feel free to provide details or alter procedures for camp setting. Please share this plan with your child’s counselor.

Does your camper demonstrate any of the following behaviors? (check all that apply)

Self-injurious behavior (bites/hits/scratches themselves)

Aggression towards peers (bites/kicks/hits peers)

Aggression towards adults (bites/kicks/hits adults)

Verbal aggression (yelling or cussing)

Elopement (any attempt at leaving an area to escape a demand)

Refusal (refusing to do daily activities)

Does your child have any "triggers" - event or situation that precedes an inappropriate response to a situation?(Required)

Yes

If your child does have triggers, please explain.

Describe the best way to encourage your child to follow directions.(Required)

How well does your child follow directions in a group setting?

My child understands and follows directions consistently

My child rarely follows directions unless extra incentive is provided

My child does not understand or follow directions

What is the best way to motivate your child?(Required)

List any strong fears your child has.(Required)

What activities does your child particularly like?(Required)

What activities does your child particularly dislike?(Required)

What are your expectations for your child while they participate in Variety Camp?(Required)

Enter any other information you feel would be beneficial to Camp staff.(Required)

RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

I am the ward or guardian of above camper, (“the child”). I am responsible for the child and have authority to sign this release on behalf of the child. Variety the Children’s Charity of St. Louis (“Variety the Children’s Charity of St. Louis”), is sponsoring SUMMER ADVENTURE CAMP.

Either the child by him or herself, I by myself, or the child and I together wish to participate in the event. There is no charge to us for our participation.

I understand that unless I sign this release, including all its terms, on behalf of the child and me, the Variety the Children’s Charity of St. Louis will not allow the child or me to participate in the event.

In order to participate in the event, on behalf of the child and myself, I therefore release the officers, directors, agents, affiliates, sponsors, volunteers, successors, assigns and employees of Variety the Children’s Charity of St. Louis from all liability for injuries or damages resulting from activities connected with the event, to the extent those injuries or damages are result of negligent acts.

I further agree to hold the released parties harmless and to indemnify them against any claims brought against them by third parties due to my actions and/or the child’s actions.

On behalf of the child and myself, I thus hereby release the released parties from all claims for damages or injuries for negligent acts connected with the event. I exclude from the release grossly negligent acts, intentional acts, and acts done with malfeasance.

I understand this release is quite broad, but I nevertheless accept its terms.

I acknowledge and agree to the Release, Indemnification, and Hold Harmless Agreement.(Required)

Yes

Media Release

I hereby authorize the media and/or representatives of the Variety the Children’s Charity of St. Louis to take photographs and/or videos of the child and me, and to publish and/or air those photographs and/or videos for the purposes of publicity and/or other reasonable purposes.

I acknowledge and agree with the Media and Photo Release.(Required)

Yes

Note: Declining the Photo and Media Release does not make your child ineligible to participate in Camp.

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Covid Waiver

We understand that the child’s participation in this activity involves a risk that the child will get sick by contracting the COVID virus. We also understand that the child, like all children, is vulnerable to problems resulting from isolation. We agree that on balance it is worthwhile for the child to bear the risk of COVID infection in order to be able to participate in the activity.

We understand that it is impossible to both engage in life’s activities and be wholly risk free. We understand that one purpose of Variety is to help children engage in life’s activities.

We understand that while Variety will attempt to conduct the activity with reasonable COVID safety protocols in place, such as social distancing and mask wearing, it will be impossible to conduct the activity with all such protocols in place at all times, and such protocols are not 100% effective anyway. COVID risks include at least involvement of many people, resistance to enforcement efforts, and people being in close physical proximity to one another.

We understand that if the child is eligible for vaccination, Variety requires us to either (a) provide proof the child is vaccinated against the COVID virus or (b) request an exemption and provide a reason for the request. We understand Variety will mandate the vaccine for employees, participants and volunteers, subject to those eligible for accommodation.

We accept that some of those involved in the activity will not be vaccinated, and we will not know who is and who is not vaccinated. We also understand that some children involved in the activity are immune-compromised and cannot be vaccinated.

We agree that if the child develops COVID symptoms we will immediately withdraw the child from the activity, we will inform Variety of the situation, we will have the child tested, and we will keep the child out of the activity until the child’s situation with COVID has abated.

Variety will inform us of any infections of any persons directly involved in the activity, but we understand that Variety reserves the right to continue the activity even if some people involved become infected. We, as parents, retain the right to remove the child from the activity at any time.

In exchange for the child having the opportunity to participate in the activity, we hereby release Variety from all COVID related liability which Variety might have as a result of the child’s participation in the activity. We understand that COVID can be fatal.

We further understand that if we do not sign this release and comply with its terms, and thus agree to bear the COVID related risks of participation in the activity, Variety will not allow the child to participate in the activity. Variety prefers all guardians or parents to sign, but a signature of one is binding.

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Parent/Guardian 1(Required)

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Parent/Guardian 2

The parties agree that this waiver may be electronically signed. The parties agree that electronic signatures appearing on this waiver are the same as handwritten signatures for the purposes of validity, enforcement and admissibility.

Variety Camp Behavior Policy

The mission of Variety Camp is to provide a supportive environment where children with physical and developmental disabilities can improve their skills and self-esteem, leading to greater socialization and independence.

Variety wants your camper to have a successful camp experience. We feel that all campers, staff, and volunteers should feel safe and comfortable in our program.

Variety staff will contact you if your child is having a difficult time participating in activities appropriately. Specific follow-up plans will be put in place following a parent-staff discussion.

If the camper’s difficulties are not able to be successfully addressed, Variety Camp reserves the right to dismiss your child if he or she exhibits inappropriate behavior or is not having a successful recreational experience. Dismissal is done at the discretion of the Camp Manager.

If your child has an IEP, 504 Plan, or any other behavior plan in place during the school year which would be beneficial at camp, send this in with your application. Please only send portions that you feel would relate to the camp experience to robin@varietystl.org.

I acknowledge the importance of the Variety Camp Behavior Policy and agree to abide by the guidelines.(Required)

Yes

Variety is committed to making the camp experience the very best for your child and your assistance is key in this commitment.

At the conclusion of camp Variety will distribute a survey seeking feedback on your camper's experience. We will use this information to guide the development of future camps.

In addition to improving the experience for your child, this information is also critical in summarizing outcomes that are accomplished in camp. Grant applications and other funding opportunities that assist in bringing this camp to life often require outcome measurements.

It is therefore a requirement/expectation that each family will complete a camp survey upon receipt of the survey. Failure to complete the survey may impact future camp attendance.

Untitled(Required)

I have read the statement above and will comply with the request.

I understand that all camp paperwork is due by May 1, 2025 in order to attend camp

Signature

Register for Summer Adventure Camp 2025

Requirements:

Camp Registration - Summer

Camper Information

Parent/Guardian Information

Additional Health Information

Preferences

General Information

RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

Media Release

Covid Waiver

Variety Camp Behavior Policy

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