Little Buddy Application

This year we are selecting 12 campers total, six from Albemarle County Public Schools and six from Charlottesville City Schools. We are looking for campers who do not qualify for ESY, are rising Kindergarteners, and are able to participate in group activities with some support. There is no cost to parents and parent transportation is preferred. Snack and lunch will be provided free for each child.

Please be sure application is complete before submitting! Application deadline: May 3, 2019.

Camper Information
Child's Name *
Child's Name
Birthdate *
Birthdate
Doctor's Phone Number
Doctor's Phone Number
Parent/Guardian Information 1
Parent/Guardian Name *
Parent/Guardian Name
Address *
Address
Primary Phone *
Primary Phone
Secondary Phone
Secondary Phone
Parent/Guardian Information 2
Parent/Guardian Name
Parent/Guardian Name
Address
Address
Primary Phone
Primary Phone
Secondary Phone
Secondary Phone
Emergency Contacts
Must include 3 names & phone numbers of persons authorized to pick up child.
Emergency Contact #1
Emergency Contact #1
Phone
Phone
Emergency Contact #2
Emergency Contact #2
Phone
Phone
Emergency Contact #3
Emergency Contact #3
Phone
Phone
Agreement
I agree to the following items for my child: *
  • My child will attend all five days, June 17-21, 8:30am - 12:30pm.
  • I can transport my child to and from camp each day.
  • My child has permission to ride the bus for field trips.
  • I give permission to include my child in photos for local media, camp brochure, etc.
  • I give permission for emergency medical care to be provided to my child by hospital or emergency medical personnel if I cannot be reached.
  • I will pick up or make arrangements for my child to be picked up, as soon as possible, if he/she becomes ill or has a major behavior upset.
  • I understand that this information will only be used to help determine my child’s eligibility for the Robin and Mani’s All Buddy Camp and will not be released to anyone other than necessary personnel.
  • I give permission to Charlottesville Parks and Recreation staff/ACPS/CCS staff to contact child’s teacher in order to process application.
  • I understand that submitting an application does not guarantee placement in the camp and I will be contacted whether my child’s applications is accepted or not.