Summer 2023 Application with Pre-Paid Deposit

"*" indicates required fields

2023 Camp Sweeney Sessions

Summer Session $4,100

PLEASE NOTE THAT THESE SESSIONS START ON A SUNDAY AND END ON A THURSDAY

Session 1: June 4 - June 22, 2023

Session 2: June 25 - July 13, 2023

Session 3: July 16 - August 3, 2023

ADDITIONAL SESSIONS & STAYOVER WEEKEND
Additional Session - $4,100 (same price)
Stayover Weekend - $800 (available only for campers attending first AND second sessions or second AND third sessions)

BEFORE YOU START THIS APPLICATION
Make sure you have all of your information:
* Guardian contact name(s), number(s), email(s), address(es), and occupation/employer
* Alternate contact name & number
* Camper's food allergies, if any
* Endocrinologist and pediatrician contact name(s), number(s), address(es)
* Financial information if requesting aid - include all income and proof of income such as tax return, W2, 1099, paycheck (REQUIRED if asking for aid, maybe uploaded now or emailed later)
* Insurance information with insurance cards, prescription cards if any. (Front and back sides REQUIRED, may be uploaded now or emailed later)
* Immunization Record with dates of vaccines (REQUIRED maybe uploaded now or emailed later)

Please make sure you have plenty of time to complete the entire application. You will not be able to save your incomplete work and finish later. We estimate the application will take 15-20 minutes if you have all of your documentation and information on hand before beginning.

PAYMENT: No DEPOSIT due with this application
This application is for campers whose deposit has been pre-paid. We will contact you if you fill this application out by mistake and have not pre-paid the deposit. In that case, we will hold your application until we receive a minimum of $500 deposit per session. You will be required to enter your credit card information for the balance of your tuition, if any. You will only be charged a nominal amount (11 cents) to validate your card.
Please review the Cancellation Policy on the parent FAQ sheet.

Point to Point Travel Service
Camp Sweeney offers a fully staffed charter travel service for campers traveling to and from DFW Airport. You do not have to have your flight information at this time. After purchase, you will receive a link and a discount code to relay your flight information without paying again. More information: Point to Point Guidelines

CAMPER info

Camper Name*
First Middle Last Suffix

Name the CAMPER prefers to be called*
This name will be on all the camper's paperwork, bedtag, and name button, and how the camper will be addressed while at camp.

Camper Sex*
Required for cabin assignment

Male

Female

Camper Date of Birth*
MM slash DD slash YYYY

Session Choice

Please choose your session*
$4,100
Please note: the number of campers we accept are limited to the number of children we can accommodate at camp. Please apply as early as possible to reserve your spot.

First Session

Second Session

Third Session

Would you like to attend an Additional Session?*
$4,100

No additional session

Yes-First Session will be my additional session

Yes-Second Session will be my additional session

Yes-Third Session will be my additional session

Would you like to attend Stayover Weekend?*
$800
Stayover Weekend is available only for campers attending consecutive sessions such as first & second or second & third.

Yes - I am attending consecutive sessions and want to attend Stayover Weekend

No stayover weekend

Diabetes Status

Is this application for a child with or without diabetes?*
The cost is the same for a child with or without diabetes.

Camper has diabetes

Camper does NOT have diabetes

PLEASE NOTE: children without diabetes will be required to test their blood sugar 5 times a day just like the children who have diabetes.

Is the non-diabetic applicant a sibling or friend of a camper with diabetes?*

Non-Diabetic Sibling

Non-Diabetic Friend

Name of Sibling with Diabetes

Name of Friend with Diabetes

Camper Information

Has Camper attended Camp Sweeney before?*

Yes

No

Where did you hear about Camp Sweeney?*

Physician Referral

Other Sweeney Family

Sweeney Meet and Greet Event

PFC Event

JDRF

Internet

Camper is non-diabetic sibling/friend

Other

Do you live within the United States?*

Yes

No the camper lives in another country

Mailing Address*
Street Address City State ZIP Code

County (not country or USA)*
As a non-profit entity, Camp Sweeney needs the county for demographic information. For example, Camp Sweeney is located in Cooke County, Texas.

International Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

4-Digit PIN for Camper Merit Tokens, ex: 1234*
This is a number your camper will use while at camp to retrieve earned merit tokens.

Current Grade in School*
Or grade just completed if filling out this form during the summer.

T-Shirt Size*
We will PRE-ORDER based on your selection so please be sure of your size.

Camper's Email (not guardian), leave blank if none

Does this camper have FOOD ALLERGIES, such as gluten or nuts, etc?*

Yes

No

If yes, please describe FOOD ALLERGIES:
List the food and the reaction

Guardian 1 Information

Guardian 1 will be listed in the camper's file. By providing this information, you are giving permission to release camper information to Guardian 1.

Guardian 1 Name*
First Last

Guardian 1 Relationship to Camper*

Guardian 1 Sex

Male

Female

Guardian 1 Email*

Guardian 1 Occupation*

Guardian 1 Employer*

Is Guardian 1 Address the same as Camper's

Yes - it is the same address

No - the address is different

Guardian 1 Address*
Street Address City State ZIP Code

Guardian 1 Phone Numbers*
Please check all the phone numbers for Guardian 1
Cell Phone
Home Land Line
Work Phone
International
None

Guardian 1 Cell Phone*

Guardian 1 Home Phone*

Guardian 1 Work Phone*

Guardian 1 International Phone*

Guardian 2 Information

Guardian 2 will be listed in the camper's file. By providing this information, you are giving permission to release camper information to Guardian 2.

Guardian 2 Name
First Last

Guardian 2 Relationship to Camper

Guardian 2 Sex

Male

Female

Guardian 2 Email

Guardian 2 Occupation

Guardian 2 Employer

Is Guardian 2 Address the same as Camper's

Yes - it is the same address

No - the address is different

Guardian 2 Address
Street Address City State ZIP Code

Guardian 2 Phone Numbers
Please check all the phone numbers for Guardian 2
Cell Phone
Home Land Line
Work Phone
International
None

Guardian 2 Cell Phone

Guardian 2 Home Phone

Guardian 2 Work Phone

Guardian 2 International Phone

Alternate Contact Information

An alternate contact is a person in the family or close to the family we can call ONLY if we cannot reach Guardian 1 or Guardian 2.

ALTERNATE Contact Name*

ALTERNATE Relationship to Camper*

ALTERNATE Contact Phone*

Doctor Information

Camper's Diabetes Doctor (Endo)*

Endo Mailing Address
Street Address City State ZIP Code

Endo Office Phone*

Does the camper have Primary Care Physician (PCP)?*

Yes

No

Camper's PCP

PCP Mailing Address
Street Address City State ZIP Code

PCP Office Phone

Financial Aid

Financial Aid is provided by Camp Sweeney with support from donors, the United Way, and private foundations. Aid is based on the camper's household annual income and the number of people living in the household. Any camper who has diabetes may apply for financial aid.
PLEASE NOTE: Amount of aid awarded cannot exceed the remaining tuition balance after other sponsorships or credits have been applied to your session account.

Would you like to apply for financial assistance?*

Yes

No

ANNUAL Gross Salary/Wage for the household*

ANNUAL Child Support/Alimony for the household*

ANNUAL Social Security/Retirement for the household*

ANNUAL Other Government Support for the household*

DOCUMENTATION PROOF OF INCOME REQUIRED:
1. Earnings/Wages: First and second pages of 2022 tax return, 2022 Form 1099(s), 2022 W-2(s) from each employer, or 2 most recent paycheck stubs from each worker or current unemployment paystub. If application is made prior to 04/15/2023, please use 2021 tax return, 1099, or W4 if a current paycheck stub is not available.
2. If you are self-employed, own your own business, and have NOT filed taxes yet, you may send a current Profit and Loss Statement.
3. Child Support/Alimony: Court order papers.
4. Social Security/Retirement: Letter from US government or 2022 retirement income tax document.
5. Government Support: Letter from US government.

Number of people living in household?*

Is this child being raised by grandparent or other family member without parent living in the household?*
Please provide medical power of attorney or custodial paperwork.

Yes

No

Is this child in the foster care system? If so, please send letter from case worker.*

Yes

No

Please provide Case Worker Name and Phone Number plus any information that may be helpful in determining financial aid.*

If your income is $5,000 or less, how do you pay for food, housing, and other living expenses? If this doesn't apply to you, please enter N/A.*

FINANCIAL AID Documentation Upload. If file exceeds limit, please email to Registrar@CampSweeney.org
Max. file size: 195 MB.

Insurance Information

Camp Sweeney does not file insurance or accept HSA cards and will not provide a list of medical charges or "super bill" for filing insurance. However, we must have your insurance information on file in case of emergency, outside medical treatment, or prescription medication.

Camper Health Insurance. Please check all that apply.*
Please provide FRONT and BACK COPIES of all insurance cards. Copies of insurance cards are required for all campers, including non-diabetics, in the event of medical treatment or prescriptions outside of Camp Sweeney.
Private, PPO, or HMO Health Insurance
Medicaid or CHIP
Prescription Card
No insurance

INSURANCE & PRESCRIPTION CARD Upload, front and back sides. If file exceeds limit, please email to Registrar@CampSweeney.org
Max. file size: 195 MB.

Immunizations - Upload record or fill in dates

Camp Sweeney is required to obtain your child's immunization or shot record. Please upload it below OR enter the dates below. If your child is a returning camper, we may have your immunizations on file.

Immunization Record
Needed immunizations:
TdaP or DTaP - not earlier than June 2015
COVID immunizations, if any
MMR - 2 shots
Polio IPV
Haemophilus influenzae type B (HIB)
Hep B - 3 shots
Hep A - 2 shots
Varicella (or date camper had chicken pox)
Meningococcal meningitis (MCV4) age 11yrs or older
If your file does not upload, please email to registrar@campsweeney.org.
Max. file size: 195 MB.

TdaP or DtaP
MM slash DD slash YYYY

COVID Vaccination (1st shot)
MM slash DD slash YYYY

COVID Vaccination (2nd shot or booster)
MM slash DD slash YYYY

COVID Vaccination (most recent booster)
MM slash DD slash YYYY

Polio IPV
MM slash DD slash YYYY

MMR dose 1
MM slash DD slash YYYY

MMR dose 2
MM slash DD slash YYYY

Hep B dose 1
MM slash DD slash YYYY

Hep B dose 2
MM slash DD slash YYYY

Hep B dose 3
MM slash DD slash YYYY

Hep A dose 1
MM slash DD slash YYYY

Hep A dose 2
MM slash DD slash YYYY

Haemophilus influenzae type B (HIB)
MM slash DD slash YYYY

Varicella (or date camper had chicken pox)
MM slash DD slash YYYY

Meningococcal meningitis (MCV4) age 11yrs or older
MM slash DD slash YYYY

IMMUNIZATION EXEMPTION
A person claiming exclusion for reasons of conscience, including a religious belief, from a required immunization must submit a notarized affidavit to our office. This may be the same paperwork used for school.
To claim an exclusion for medical reasons, the child must present an exemption statement to the camp, dated and signed by a physician (M.D. or D.O.), properly licensed and in good standing in any state in the United States who has examined the child.

Text Notification

Would you like to receive text messages with information about Camp Sweeney events that occur throughout the year?*
These events include PFC Life, ePFC, JDRF Walks, and other community events. You can opt out of this service at any time. Carrier and messaging rates may apply.

Yes

No

Phone 1 Camper's Cell

Phone 2 Guardian Cell
For mother/guardian

Phone 3 Guardian Cell
For father/guardian

INDEMNITY & RELEASE Please read carefully and SIGN below

I, the Parent/Guardian, on behalf of my minor child, as listed above, understand that use of the Southwestern Diabetic Foundation and/or Camp Sweeney facilities and participation in facility programs and events creates a risk of injury and/or illness and therefore expressly consent to and assume all risks associated with use of the Southwestern Diabetic Foundation and/or Camp Sweeney facilities and participation in their programs and events, even those which are not specifically foreseeable, and release, indemnify, defend, and hold harmless Southwestern Diabetic Foundation, Camp Sweeney and their directors, officers, employees, and agents (the “Released Parties”), from any loss, liability, claim, action, or suit (“Claim”) arising or alleged to arise from (A) bodily injury or personal injury suffered by any party on the Southwestern Diabetic Foundation and/or Camp Sweeney facilities, (B) bodily injury or personal injury caused by a participant in facility programs and events (including off-site trips), (C) illness contracted while participating in Camp Sweeney events, and/or (D) property damage or loss suffered in connection with, or as a result of, my or my minor child’s use of Southwestern Diabetic Foundation and/or Camp Sweeney facilities or participation in their programs and events (including off-site trips), regardless of whether such claims and actions are founded in whole or in part upon alleged negligence of the Indemnified Parties. I specifically and explicitly release, indemnify and hold harmless the Released Parties (defined above) from all liability, claims, demands, actions or rights of action, or damages of any kind including but not limited to those arising out of or relating to any one or more of the Released Parties’ own sole, contributory and/or comparative negligence. I knowingly and voluntarily release, indemnify and hold harmless the Released Parties from any such claims. I have read and understand the above waiver. This Indemnity and Release is made and is performable in Cooke County, Texas. I agree that exclusive venue for all claims arising from or related to this agreement, including claims for personal injury or illness, lies in Cooke County, Texas.

PARTICIPATION: I, the Parent/Guardian, give permission for my child to participate in all of the Camp Sweeney program activities on or off the Camp Sweeney property including activities conducted virtually.

VIDEO/PHOTOS: Many pictures, videos (live and recorded), internet broadcasts and interviews will be taken of all the children who participate in Camp Sweeney in-person and digital events throughout the summer and coming year. I give the Southwestern Diabetic Foundation, Inc. permission to use the pictures, interviews, live and recorded internet broadcasts, internet pictures and videotapes of our child in any of its publicity campaigns and/or websites.

TREATMENT: I authorize the medical staff at Camp Sweeney or Southwestern Diabetic Foundation to administer or authorize routine and emergency medical treatment in my absence. I understand that every reasonable effort to notify me will be made prior to rendering emergency treatment. I understand that if any medical expenses occur during the course of camp including x-rays, blood tests, medications, and/or emergency room visits, the camper’s guardians will assume financial responsibility for expenses not covered by the camper’s insurance. In addition, both the camper and the camper’s guardian agree for the release of any medical information acquired by Southwestern Diabetic Foundation and/or Camp Sweeney to be released to the camper’s referring physician.

BEHAVIORAL RULES/PROCEDURES: The camper and the camper’s guardian agree that the camper will abide by the behavioral rules and procedures set forth by Camp Sweeney for the safety of all campers and staff.

CANCELLATION POLICY: You may cancel your enrollment by sending a written request for unenrollment. An email to our registrar@campsweeney.org is acceptable. Cancel 90 days prior to beginning of session - Full Refund of deposit and payments. Cancel 60-89 days prior to beginning of session - Deposit will be rolled over to next year. Payments, if any, will be refunded or rolled over by request. Deposit is forfeit if not used next year. Cancel 2-59 days prior to beginning of session - Your deposit is non-refundable and will not roll over to next year. You will be refunded for any other payments made. Failure to show on opening day or cancel your session at least 2 days in advance will result in forfeiture of all payments and deposits made for that session as we have reserved that space specifically for your child.

EARLY DEPARTURE POLICY: Your child might have to leave camp prior to the scheduled last day of the session. These reasons include, but are not limited to, medical reasons, behavioral reasons, acts of God, family emergency, voluntarily or involuntarily. It is not permissible to sign up with the intention of completing a partial session. Tuition for 1 to 7 days in session is $2,000. Tuition for 8-11 days in session is $3,050. Tuition for 12-19 days in session is the full tuition amount.

PAYMENT: I, the Parent/Guardian, acknowledge that the balance of the total tuition fee as detailed in this application less financial aid or sponsorship, if any, is my financial responsibility. I understand that the remaining balance is divided equally into monthly payments to be paid in full by February 2024. I authorize Southwestern Diabetic Foundation to automatically charge the credit card provided in this application, or charge an alternate payment method I provide, until the balance is paid.

I, the Parent/Guardian, certify that the information provided in this application is true and correct and authorize investigation of these facts by any authorized representative of Camp Sweeney.

I have read and agree to all the above releases and authorizations with regards to the camper’s stay at Camp Sweeney.

Guardian's Signature of Release (type in name)*
By typing in your full name, you agree to all of the above releases and authorizations with regards to the camper's stay at Camp Sweeney.

Last 4 digits of signer's Social Security Number*

Is signer Guardian 1 or Guardian 2?

Signer is Guardian 1 listed in this application

Signer is Guardian 2 listed in this application

Today's Date*
MM slash DD slash YYYY

PAYMENT

Payment date(s)*

One payment on April 4, 2023, for the balance less aid if applicable

Monthly payments on the 1st day of each month starting next month

Monthly payments on the 15th day of each month starting next month

NO ADDITIONAL PAYMENTS. I believe my balance is paid in full. I understand that if it is not paid in full that my card will be automatically processed on the 1st day of each month.
Camp Sweeney will contact you regarding your payment amount before processing the first payment. If you qualify for Financial Aid, the aid will be subtracted from your balance due. If you need to update your credit card number or expiration date or change your payment due date, please contact the camp office at least 2 business days prior to the payment due date. PLEASE NOTE: when choosing the one payment option, your balance will be charged on the date listed above or 1 month after application submission, whichever is latest.

PLEASE NOTE: when choosing the one payment option, your balance will be charged on the date listed above or 1 month after application submission, whichever is latest.

Point to Point Travel Service

FIRST SESSION
Arrival Window: Saturday, 6/3/23, 2:00pm to 6:00pm
Departure Window: Thursday, 6/22/23, after 1:30pm
SECOND SESSION
Arrival Window: Saturday, 6/24/23, 2:00pm to 6:00pm
Departure Window: Thursday, 7/13/23, after 1:30pm
THIRD SESSION
Arrival Window: Saturday, 7/15/23, 2:00pm to 6:00pm
Departure Window: Thursday, 8/3/23, after 1:30pm

Point to Point Service*

Round trip $1,000

Arrival only $700

Departure only $700

No Point to Point Service

TO PROVIDE FLIGHT DETAILS:
Once you have reserved your flight, please go to:
www.campsweeney.org/register-point-to-point

CHECK OUT

Total Due Today

Credit/ Debit Card (Visa/MC/Disc/Amex)

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date Month Year
Security Code Cardholder Name

Country
Country

Cardholder Street Address*

Cardholder City*

Cardholder State*

Cardholder ZIP Code*

Cardholder Email*

Cardholder Phone*