Pathways to Success Programs explore Cooking and Nutrition
2015 Healthy Cooking and Nutrition Summer Camp
Application Form
COOKING AND NUTRITION SUMMER CAMP
The 2015 Cooking and Nutrition Summer Camp teach kids how to select and prepare
healthier food options from scratch! Kids will learn basic cooking skills, knife skills,
kitchen safety, dining etiquette and more! Each day will focus on a different lesson and
menu, and kids will dine on their own culinary creations!
Dates: June 15th-19th (Middle) & June 22nd- 26th (High)
Time: 9 a.m. - 12 p.m.
Location: Jenkins High School
Eligibility: 50 participants, ages 12- 18 years old with an interest in improving math skills.
Required: A letter of recommendation from teacher, guidance counselor or supervisor in
addition to the application form. There is a $75 registration fee (money order). Cost: $75:
Includes Screen printed Apron, All Supplies and Daily Recipes.
PARTICIPANT INFORMATION:
Name:
___
__
Age: ____
Sex:
□ Male □ Female
T-Shirt Size: □ Child /□ Adult: □ Small □ Medium □ Large
School _____________________________________________________________
GPA_____________
Email[s]: _____________________________________ / _______________________________________
Cell phone[s]:
(______ ) _________________________
(______ ) ____________________________
I hereby apply to be a member of the SAVANNAH 100’s YOUTH and I understand and agree to abide by its
requirements. I promise to be kind and respectful to my fellow students and all others.
Participant Signature: ________________________ Date: ______________________________________
PARENT OR GUARDIAN INFORMATION:
Name:
___
__
Date:
___
Address:
_________
City:
______
Phone:
State:
Zip:
Alternate Phone:
Email:
___
___
___
Any Food Allergies_________________________________________________________________
Email:____________________________________________________________________________
Camp Policies
1. There will be no refund unless the session is cancelled due to lack of enrollment.
2. Children must be well-behaved at all times. In the case of discipline problems, parents
will be called.
3. Your child may be using sharp knives, may be cooking around a hot stove, or hot oven.
4. Absolutely no open toe shoes (ex. sandals or flip-flops); rubber sole shoes required. Long
hair must be tied back.
5. Parents must be available by phone should an emergency arise.
6. Food Allergies: We are unable to accommodate children with severe allergies, vegetarian,
gluten-free and restrictive diets. We do not use nuts in any of our recipes.
Consent, Release and Waiver Form
I, ________________________, the parent and/or guardian of _______________________ (“Mentee”),
hereby give my consent for him/her to participate in the 100 Black Men of Savannah, Inc. (“Savannah
100”) youth mentoring programs. I also agree that:
1. Program staff, volunteers, Collegiate 100, and members of the Savannah 100, have my
permission to provide Mentee reasonable first aid and transportation to a health care facility in
the event Mentee needs emergency medical attention. I agree to release any records necessary
for treatment, billing, referral or insurance purposes in the event Mentee is transported to a
health care facility for emergency medical attention.
2. Pictures and video or audio recordings of Mentee participating in the Program are hereby
released by me for use in appropriate news media (e.g. newspapers, radio, and television
stations) and in the marketing materials for the Savannah 100 (e.g. website and brochure).
3. In consideration of Mentee being allowed to participate in the program I agree on behalf of
myself, Mentee, any other parent or guardian of Mentee, and any personal representative,
agent, heir, successor or assign of the foregoing (hereinafter “Mentee’s parties”) to forever and
irrevocably indemnify, hold harmless, waive liability, release and discharge Savannah 100, 100
Black Men of America, Inc., Program staff, and any corporate entities, officers, directors,
members and employees related to any of the Program from any and all claims, demands,
causes of action, rights, costs and charges of whatever kind or nature, arising out of or related
to any known or unknown, foreseen or unforeseen bodily or personal injury, death, or property
damage, resulting from Mentee’s voluntary participation in Program.
4. In consideration of Mentee being allowed to participate in the Program, I covenant and agree on
behalf of Mentee’s parties that Mentee’s parties will not sue Program parties for any claims for
damages arising from or related to Mentee’s voluntary participation in Program.
5. Assumption of Risks: Engagement in Athletic Activities carries with it certain inherent
risks that cannot be eliminated regardless of the care taken to avoid injuries and that
participation in any physical activity involves peculiar risks that even when safety
precautions are utilized, injuries can occur. I also understand that if I experience pain or
physical discomfort during these activities I will decrease or stop participating. I am
aware that personal health/accident insurance is my sole responsibility. I affirm that to
the best of my knowledge, I do not have any medical condition or physical disability that
will preclude my safe participation.
6. I have read the previous paragraphs and I know, understand, and appreciate these and
other risks that are inherent in The Engagement of Athletic Activities and participation in
attendant activities. I hereby assert that I knowingly assume all such risks.
I hereby acknowledge that I have read this form and agree to waive certain legal rights by signing this
Consent, Release and Waiver.
Parent/Guardian:
Signature:______________________________________________ Date:_______________________
SCHOLARSHIP SECTION
HOUSEHOLD INFORMATION
Household Size:
□-1
□-2
□-3
□-4 □-5
□-6
□-7
□-8
□-Other
______________
[please specify]
Total Household Annual Income $ ____________________________
Proof of Income: ________________________________________ (W4s; Pay-Stubs; Award Letters; etc.)
Who is financially responsible for the child’s tuition? __________________________________________
In order to qualify for a private scholarship for the $75.00 participation fee, you must have an annual
household income (before taxes) that is at or below the following amounts:
MAXIMUM INCOME LEVEL
YOUR FAMILY
(PER YEAR)
(CHECK ONE)
HOUSEHOLD SIZE*
1
$15,171
2
$20,449
3
$25,727
4
$31,005
5
$36,283
6
$41,561
7
$46,839
8
$52,117
*For households with more than eight people, add $5,278 per additional person.
Please complete the application and return a mail copy to before May 29th 2015:
Pathways to Success Programs/ Cooking Camp
ATTN: Mrs. Q. Joyner
P.O. Box 14606
Savannah, GA 31416