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PPB Youth Camp Application

Annual Rosenbaum PPB Youth Camp

June 17-21, 2019 · 9:00 am-3:00 pm
Parkrose High School – 12003 NE Shaver St, Portland, OR 97220

Please fill out the application below.  After you complete the information and submit, you’ll be directed to a second page to provide payment via PayPal.

PPB Youth Camp Application

  • Child Information

  • Camp Staff will not administer medications. Those with special dietary needs or allergens should bring their own lunch.
  • Parent/Guardian Information

  • Emergency Contact

  • (Other than parent or guardian)
  • T-Shirt Size

  • Activities

  • Please identify your first, second and third activity preference. Please note that some activities fill up quickly. Activity choice will be based on a first come, first served basis. No reserved spots. Payment must be received before placement can occur.
    Note: Youth will not be allowed to switch activities after the first day of camp.
  • Parent/Guardian Consent

    If yes, please email a copy of the free/reduced lunch form to ppbyouthcamp@camprosenbaum.org. We must receive this documentation to approve the reduced camper rate of $20.
  • PARENT OR GUARDIAN STATEMENT: I have read the description of Rosenbaum PPB Youth Camp (the “Camp”) and its activities (the “Activities”), and understand the scope and potential demands of the Activities. To the best of my knowledge, I believe that the child identified above (the “Child”) is physically and mentally able to participate in the Activities. Child is not suffering from, nor has Child been exposed to, any condition that might be harmful to other children or camp staff. WAIVER AND RELEASE: I acknowledge that Child’s attendance at the Camp, and Child’s participation in the Activities, involves acceptance of certain inherent risks, including physical injuries, accidents, illness or death. For myself and Child, I assume all risks of Child’s attendance at the Camp and Child’s participation in the Activities. In consideration of allowing Child to attend the Camp, and to participate in the Activities, I, as parent or legal guardian of Child, on behalf of Child, myself or respective heirs, personal representatives, and assigns, hereby release Camp Rosenbaum Fund, the Portland Police Bureau, Parkrose School District, and their affiliated companies, and any of their shareholders, members, directors, officers, managers, employees, agents and volunteers (collectively “Released Parties”) from any and all claims resulting in personal injuries, accidents, illnesses, death, property loss, or other losses (collectively “Claims”) arising out of or in connection with Child’s attendance at the Camp or participation in the Activities. I, as parent or legal guardian of Child, on behalf of Child, myself, and our respective heirs, personal representatives, and assigns, waive any Claims that might otherwise exist arising out of or in connection with Child’s attendance at the Camp or participation in the Activities. The release and waiver granted by this paragraph includes, but is not limited to, claims resulting from the negligence of the Released Parties. MEDICATIONS AND EMERGENCY MEDICAL TREATMENT: The Camp’s staff will NOT administer any medications to Child while Child is attending the Camp. I, as parent or legal guardian of Child, give permission for Child to receive emergency medical or surgical treatment and/or hospitalization if necessary. PUBLICITY: On behalf of Child and myself, I give my permission and consent to Camp Rosenbaum Fund to allow, without compensation to Child or me, photographs and video to be taken of Child during the week of camp. I agree that any such photographs or video may be published or used in any and all print, electronic, or social media platforms of any kind and nature for the purpose of raising awareness in the community about the Camp and its activities, mission and purpose. Such use may include memorabilia, publications, media and promotions (such as newspaper articles, social media or television) and presentations to sponsors.
  • Please type your name above. By typing your name and clicking the button below, you are electronically signing this application.

The Rosenbaum PPB Youth Camp does not discriminate against any child on the basis of race, religion, color, sex, marital status, familial status, national origin, age, mental or physical disability, sexual orientation, gender identity or source of income or because of a need for special care. Our goal is to meet the individual needs of each child within the structure of our program while maintaining a safe and healthy environment for all children and staff.