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The Energy Commission has held the Energy Camp here in Wake County since 1994. Rising sixth-grade students who reside in Wake County participate in a wonderful array of energy-themed activities for one entire week during the month of July. Wake County educators conduct hands-on energy demonstrations, conservation-themed projects and various field trips and site visits to allow all 40 participants to have a fun and information-filled week. While snacks are provided, campers need to bring a lunch every day.
Application fees are held to $200 through the assistance of corporate sponsorships and individual donations. The
Energy Camp awards partial scholarships as available. For scholarship application information or payment by credit card please contact Ms. Golden Graham, Wake General Services (919) 856-5777.
Please note that all required fields on all 6 pages of the application must be completed and signed prior to submission to Wake County Citizens Energy Advisory Commission to be considered for acceptance.
:
401 Capital Boulevard
Raleigh, NC 27603
8:00am Drop-Off
4:30pm Pick-up

Full Legal Name:
Last First M.I.
First Name as you’d like to be referred to (if different from above)
Address:
Street Name/Number City State Zip Code
Sex: Male _____ Female _____ Birth Date (mm/dd/yyyy):___________________________________________________
Phone: (_____) Email: ___________________________________________________
School name: ___________________________________________________________________________________
Parent/Guardian Name _______________________________________
Cell Phone _________________________________________________
Work Phone________________________________________________
Home Phone________________________________________________
Parent/Guardian Name _______________________________________
Cell Phone _________________________________________________
Work Phone_________________________________________________
Home Phone________________________________________________
EMERGENCY CONTACT:
When parents/guardian cannot be reached, list at least one person who may be contacted to pick up the child in an emergency.
Name__________________________________________________________________________
Home Phone _________________ Work Phone______________________________ Cell Phone_________________

Medical Information:
Name of Health Insurance Provider_______________________________________________
Policy Number________________________________________________________________
Primary
Physician____________________________________________________________________________________
Phone_______________________________________
Please list any medical issues, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).
Please include any developmental or special needs information that affects your child.
Condition Required treatment
_______________________________ ____________________________________
_______________________________ ____________________________________
_______________________________ ____________________________________
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
Yes__ No__ If yes, explain:_____________________________________________________
Is your child allergic to any type of food or medication?
Yes__ No__ If yes, explain:______________________________________________________
Does your child require a special diet?
Yes__ No__ If yes, explain:______________________________________________________

I understand and acknowledge that during the camp there are some risks of injury to my child, and that my child may participate in camp activities, such as indoor and outdoor games, group tours, and transportation to and from activities, during which accidents, injury or illness could occur. I give permission for the camp and its agents and counselors to seek and/or provide any medical assistance that they believe to be appropriate in the event of illness or accident. I also give permission for hospital or other emergency personnel to treat my child in the event of an emergency, illness or accident. I agree to be responsible for any expenses incurred to treat my child for an emergency, accident or illness. I represent that the medical information about my child provided in this Application is accurate and complete to the best of my knowledge, information and belief. In return for the opportunity to participate in the camp and its activities and expeditionary trips, I, for myself and my minor child, assume all risk of accident, injury or other harm at the camp. I, for myself, and my minor child agree to release, indemnify, and hold harmless the camp, the Wake County Citizens Energy Advisory Commission, the Wake County General Services Department,
Wake County and their respective counselors, agents, representatives, and employees, from any and all claims for medical expenses, personal injury, bodily injury, or wrongful death resulting from any accident, illness, injury or other occurrence during camp, whether caused by the negligence of the camp or its representatives or otherwise. It is my intent that this acknowledgement, release and waiver of liability be binding on and effective against my spouse, heirs, legal successors, assigns and next of kin. This release is meant to be as broad and inclusive as is allowed under
North Carolina law. If any portion of this release is found to be invalid, the remaining terms shall remain in full force and effect.
I have read and fully understand this release.
___________________________________________________________________________________________
Signature of Parent/Legal Guardian Date

Camper’s Name: ___________________________________________________________________
The Wake County Citizens Energy Advisory Commission and its Energy Day Camp counselors have established the following goals and expectations for conduct and behavior during the week long camp adventure. All of the counselors, campers and their parents and guardians are asked to work toward these goals and expectations. Every camper and his or her parents or guardian must accept this Code of Conduct Agreement before the camper will be permitted to attend the Camp and participate in its activities.
 We will not bring weapons of any kind to camp.
 We will be respectful of ourselves, others and property.
 We will listen and be attentive to the counselors and follow their directions.
 We will exhibit self-discipline.
 We will use good manners.
 We will be honest and fair.
 We will be kind to all of our fellow campers.
 We will not bring toys or games to camp without the approval of the counselors.
 We will not use mean or inappropriate language.
 We will not hit each other deliberately nor do anything meant to harm another camper or counselor.
 When we are on tours or expeditions we will respect the tour guides and their property.
 When we are on the bus we will follow directions given by the camp counselors and the bus driver.
 We agree that the counselors may remove anything we have agreed we will not bring to camp.
 We agree counselors may remove any item that is causing a disturbance or deemed dangerous.
 We agree that counselors may use “time out” or otherwise separate campers who are not meeting the goals and expectations expressed in this agreement.
 Any camper who is not meeting the goals and expectations of camp, may be expelled from camp without refund of the camp fee.
 We will have an educational AND awesome week!
CODE OF CONDUCT AGREEMENT ACCEPTANCE
I have read and I understand the Wake County Energy Day Camp Code of Conduct above and I agree to abide by the rules. I understand I may be removed as a participant from the activity or program, if I fail to follow these rules and no refund of the camp fee will be made.
___________________________________________________
Signature of Camper
__________________
Date
I expect my child to abide by this Code of Conduct.
___________________________________________________________________________________________
Signature of Parent/Legal Guardian

Camper’s Name: ____________________________________________
I give permission and consent to allow photographs and video to be taken of my child during camp session activities.
I further give permission and consent that any such photographs or videos may be published and used by Wake
County and the Wake County Energy Camp in news releases or promotional materials to illustrate and promote the camp experience. These promotional materials may include printed or electronic publications, web sites or other electronic communications. I authorize the use of these images without compensation to me or my child. I further release Wake County and the Wake County Energy Camp from any expectation of confidentiality.
Parent/Guardian (signature)____________________________________
Date:________________________________________________________________________