Dharma Camp Tuition Payment Home Children’s Programs Dharma Camp Dharma Camp Tuition Payment Dharma Camp will be July 23 – 28, 2023 at Molalla Retreat. Tuition is $550, a deposit of $100 is required to reserve your spot. Scholarships are available, please reach out to Shin’yu Vitells at *protected email* for more information. Dharma Camp 2023 Camper Name(Required) First Last Date of Birth(Required) Camper Gender(Required) Camper Pronouns(Required) Grade for Fall 2023(Required)Please enter what grade the camper will be entering into for fall 2023. Camp T-Shirt Size(Required)Please indicate shirt size below CHILD Small CHILD Medium CHILD Large CHILD X-Large ADULT Small ADULT Medium ADULT Large ADULT X-Large ADULT XX-Large Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent InfoPlease enter the parent names, emails, and phone numbers below. Parent Name (1)(Required) First Last Parent Email (1)(Required) Parent Phone (1)(Required)Please enter the second parent's info below.Parent Name (2)(Required) First Last Parent Email (2)(Required) Parent Phone (2)(Required)Emergency Contact(Required)Who shall we notify in case of emergency? The FIRST PARENT listed on this form. The SECOND PARENT listed on this form. Someone else EMERGENCY CONTACT NAME(Required) First Last Emergency Contact - Relationship to Child(Required)What is the relationship to the camper? (i.e. grandparent, cousin, friend of family) Emergency Contact - Phone(Required)Are you a dues paying member of Dharma Rain? Yes No Health InventoryDoes the camper have health insurance?(Required) Yes No Insurance Provider(Required) Subscriber ID Number(Required) Family Plan(Required)If the child is a dependent on a family plan, who is the primary on the insurance? Primary Care Physician Name(Required)Please indicate the camper's primary care doctor and their clinic name below. Primary Care Physician Phone Number(Required)Does the camper have dental insurance?(Required) Yes No Dental Insurance Provider(Required) Dental Insurance Subscriber ID(Required) Dental Family Plan(Required)If the child is a dependent on a family plan, who is the primary on the insurance? Dentist Name and Clinic(Required) Dentist's Phone Number(Required)Does the camper have a medical or mental health condition that a doctor or medical professional should be informed of in case of emergency?(Required) Yes No Please provide a specific description below:(Required) Does the camper have a drug or medication allergy?(Required) Yes No Please provide a specific description of the drug/medication allergy below:(Required) Does the camper have allergies or sensitivity to any foods?(Required) Yes No Please indicate what food allergies / sensitivities the camper has below:(Required) Does the camper have a chronic or recurring illness that might affect their participation in camp activities?(Required)Please include information about chronic runny nose or seasonal allergies or asthma. Yes No If yes, Please describe the chronic or recurring illness below:(Required) This camper may be given regular over-the-counter medications (check all that apply):(Required) Acetaminophen Aspirin Ibuprofen Cough Medicine Diphenhydramine (Benadryl) This camper has prescription medication that may be self-administered per physician's instructions(Required) Yes No Please describe below:(Required) Covid Exposure Notification(Required)Should we discover a covid exposure during camp, how do you wish to be notified? Phone call Text Message Email Supporting the Camper Experience(Required)Please tell us of any concerns you have about the camper's comfort or what might interfere with the success of an overnight camp experience. We would appreciate insight into strengths, weaknesses, and/or idiosyncrasies of the camper's character and physical being. ConsentsConsent to Medical Treatment(Required)This camper may be given any and all medical treatment deemed proper and necessary by an attending physician in case of emergency. I give my consent to medical treatmentCovid Rapid Test Consent(Required)Should a camper exhibit symptoms of Covid-19 at camp, camp staff may administer a rapid Covid test. I agree to camp staff administering a rapid covid test should my child become symptomaticPhotography Consent(Required)I understand that photographs and videos may be taken at Dharma Camp. I hereby give permission for the use of such images of my youth to be used for the promotion of Mandala on the Mountain or DRZC. I understand that children are never identified by name in publications, unless by express permission of the parent(s) (and if the child is old enough to object). See DRZC Photo and Video Policy for further information. I understand and give photography consent.Liability(Required)I have filled out this form fully and accurately to the best of my knowledge. I agree to release Northwest Zen Sangha, Dharma Rain Zen Center, and the staff of Mandala on the Mountain Dharma Camp from any liabilities that might accrue from reasonable and normal activities during the time my child is in their care. (Please type your name and today's date.) Camp Payment(Required)Camp tuition is $550. You can also hold a space with a deposit of $100, the balance of camp tuition will be due by July 1st. For those who are paying deposits ONLY now, you can choose to pay the camp balance by PayPal or check to DRZC. Deposit ($100) Full Camp Tuition ($550) Electronic Payment(Required)To pay online, choose the Pay via Paypal option. On the next screen, you will have the option to select a payment method of Paypal, credit card, or debit card. You do NOT need a Paypal account to pay via credit or debit card. 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