MHABC School Break/Day Camp

Notice: Effective 1/1/24, MHABC will no longer be providing care for breaks/out-of school days for Western Boone Schools when those days do not coincide with Lebanon Schools out-of-school days/breaks. This is due to compliance with our early learning program at our building, as well as availability of staff. Please call 482-3020 with any questions.

MHABC School Break/Day Camp

Welcome to the MHABC School Break/Day Camp sign-up form specifically for school breaks and out-of-school days. The full calendar is listed below. Please note that your child's site location may have changed based on their age (see below). Please complete the form and hit submit.

Location: 515 E Williams Street (Central Elementary)
Hours: 6:30 AM to 6:00 PM
Additional fees apply - please see fee schedule on the website.
Please bring a sack lunch. A breakfast item and an afternoon snack will be provided.

2023-24 Calendar:

Spring Break (Lebanon) 3/22, 3/25-3/29
Spring Break (Western Boone) 3/25-3/29
PD Day/Eclipse Day (Lebanon & Western Boone) – 4/8

"*" indicates required fields

Parent #1*

First Last

Parent Email #1*

Parent Cell Number #1*

Parent #2

First Last

Parent Email #2

Parent Cell Number #2

How many children are you signing up?*

Child #1*

First Last

Child #1 Age*

Please note that your child's site location may have changed. Refer to the top of this page for more information.

What school does child #1 currently attend?

Child #1: Allergies, Medical Issues, and Behavior Concerns*

Please list all that apply for each child (see example below). Type NA if none.

If medical administration is needed by our staff, the Medical Release form will need to be signed. Please provide the medication name that your child is taking, the dosage, and the frequency.

Child #2*

First Last

Child #2 Age*

Please note that your child's site location may have changed. Refer to the top of this page for more information.

What school does child #2 currently attend?*

Child #2: Allergies, Medical Issues, and Behavior Concerns*

Child #3*

First Last

Child #3 Age*

Please note that your child's site location may have changed. Refer to the top of this page for more information.

What school does child #3 currently attend?*

Child #3: Allergies, Medical Issues, and Behavior Concerns*

Which break/day signing up for?*

You can choose one or more. Refer to the calendar above for the exact dates.

Fall Break - Lebanon

Fall Break - Western Boone

Winter Break - Lebanon

Winter Break - Western Boone

Martin Luther King, Jr. Day

Spring Break - Lebanon

Spring Break - Western Boone

PD Day/Eclipse Day (Lebanon & Western Boone)

Authorized Pick-up #1

Please designate family/friends that are authorized to pick-up your child. You do not need to include yourself or parent #2.

First Last

Authorized Pick-up #2

Please designate family/friends that are authorized to pick-up your child. You do not need to include yourself or parent #2.

First Last

Authorized Pick-up #3

Please designate family/friends that are authorized to pick-up your child. You do not need to include yourself or parent #2.

First Last

Are you a current B.A.S.E. or YSPP customer?*

Address*

As a new customer, please provide your home address.

Street Address Address Line 2 City State ZIP Code

Parent Consent*

I agree to the parent consent.

MHABC BREAK/DAY CAMP PARENT AGREEMENT – Breaks and Out of School days during Regular School Year – PLEASE READ THE FOLLOWING COMPLETELY – YOU ARE MAKING MULTIPLE AUTHORIZATIONS BY SIGNING THIS DOCUMENT, INCLUDING MEDIA RELEASE, GENERAL LIABILTY RELEASE, TRANSPORT RELEASE, MEDICAL RELEASE, and more:
For my child’s attendance in MHABC CAMP during school breaks and days off, I agree to the following:
1. I will adhere to the breaks chosen on the form submission;
2. ANY AND ALL CHANGES/CANCELLATIONS MUST BE COMMUNICATED TO THE BASE OFFICE IMMEDIATELY at (765) 482-3020 x100 or x103 OR BY EMAIL TO BFETTIG@MHABOONECOUNTY.ORG.
3. A 25% CHARGE WILL APPLY UNLESS AT LEAST A 24 HOUR NOTICE OF CANCELLATION HAS BEEN PROVIDED TO THE MHABC VP OF BUSINESS, BECKY FETTIG AT BFETTIG@MHABOONECOUNTY.ORG (NOTE: PLEASE DO NOT PROVIDE CHANGES/CANCELLATIONS TO BASE SITE STAFF).
4. I understand that the dates/breaks I select for my child on the registration will determine my billing;
5. I agree to be responsible for all expenses incurred for medical and/or emergency transportation costs;
6. I authorize MHABC to transport my child for purposes such as special activities/clubs/field trips (which will be communicated to parents in advance), or to receive necessary medical attention. I recognize and acknowledge that there are certain risks of physical injury associated with being transported by bus/car by an MHABC staff member. I agree to assume the full risk of injuries that may be sustained by any minor child/ward of mine, as a result of being transported by bus/car by an MHABC staff member and all activities connected or associated therewith. I agree to waive and relinquish all claims on behalf of my minor child/ward that the minor child/ward may have against MHABC as a result of the minor child/ward’s being transported by bus/car/other vehicle by an MHABC staff member.
7. I have provided all necessary information regarding my child(ren)’s medications, allergies and medical conditions. I understand that if my child uses an Epi-pen or similar device, I MUST provide this to the MHABC administration prior to my child’s attendance at MHABC camp.
8. I understand that I and the other parent will initially be required to present a photo I.D. when picking up my child until site staff becomes familiar with us. I understand that when a person other than myself or the other parent will be picking up my child, that individual needs to be on the authorized pickup list and must provide a picture ID in order to be permitted to pick the child up. I further understand that if I need to make a change to the authorized pickup list, I must do so in writing to PFETTIG@MHABOONECOUNTY.ORG by using the email listed on my MHABC account, preferably with a 24 hour notice. If I am unable to give a 24 hour notice of a change, I will call the MHABC office at (765) 482-3020 x100 and inform staff of the change, and also do so in writing to PFETTIG@MHABOONECOUNTY.ORG.
9. I understand that if custody or a protective order are an issue affecting who may or may not pick up my child(ren), I will IMMEDIATELY communicate this to MHABC administration at 765-482-3020 x100 and provide a copy of the relevant court order. I understand that without a court order stating otherwise, MHABC staff cannot prevent a legal parent from picking up a child. I further understand that if the child I am registering is a ward of the state, I will let the administration know by contacting the CEO at 765-482-3020 x100, or emailing him at pfettig@mhaboonecounty.org and by providing any related paperwork to administration.
10. I understand that all MHABC staff are mandated to report any signs of abuse or neglect;
11. I understand MHABC reserves the right to exclude any child from camp or request that a child be picked up from camp should the child be exhibiting symptoms related to any illness if those same symptoms would require a child be excluded or sent home according to school policies. I understand this could affect my childcare plans and that I should have backup plans in place should this occur.
12. I understand that my child may be denied enrollment until the registration and all pertinent acknowledgments and forms are submitted, and that submitting this form in close proximity to the time at which I need my child(ren) to begin the program could impact my child(ren)’s start date.
13. I understand my child(ren) can be denied attendance in the case of non-payment.
14. I understand that a $15/week late fee may be added as a result of an unpaid invoice.
15. I understand that I must pick my child(ren) up before 6:00 p.m. or a $5.00/minute, per child fee will accrue and I will be expected to make payment immediately to the MHABC site staff or the next business day to MHABC administrative staff.
16. I/we, the parent(s) of the registered child(ren) acknowledge that I/we are responsible for any unpaid balance for attendance fees, late fees, and finance charges associated with my/our account;
17. I/we, the parent(s) of the registered child(ren) acknowledge that I/we are responsible for attorney’s fees required for purposes of collection of any unpaid fees herein, plus any and all costs of collection, including court fees.
18. I understand MHABC’s polices and procedures related to camp may change depending on various factors, and that MHABC administration reserves the right to do so. If that occurs, I understand that I will receive communication regarding such change.
19. I/we agree to contact MHABC administration at (765) 482-3020 x100 with any and all questions related to this document.
Photo/Video/Media Release: I hereby authorize MHABC staff to capture, edit, and use my child’s video and/or photographic image solely for the purposes of sharing information about the MHABC youth programs and for promoting and advertising the program on the MHABC social media pages and website, in newspapers and newsletters, via e-mail and via other forms of media. In doing so, I release MHABC and its staff, representatives, board members, and agents from all claims, demands and liabilities whatsoever in connection with the above.
PARENT: If you do NOT want your child’s image used in this manner, please email PFETTIG@MHABOONECOUNTY.ORG immediately upon submitting your registration and advise you do not want your child’s image used. Please maintain record of such communication. *Note: If the child you are registering is a ward of the State of Indiana, you MUST inform of us of this information and we will NOT post their image, even with permission.
Medical Treatment Release: I hereby consent to emergency medical treatment of my child(ren) herein registered, during MHABC camp operation hours, should I not be able to be reached, to ensure prompt treatment and prevention of undue delay. I understand such treatment, other than first aid required to be rendered immediately by an MHABC staff member, will be provided by either a licensed physician or individual trained in emergency care.
General Liability Release: I, individually, and on behalf of my minor child(ren) and our respective heirs, successors, assigns, and personal representatives, hereby release, acquit, indemnify, hold harmless and forever discharge Mental Health America of Boone County and their administration, staff, site leaders, designated volunteers, agents, board members, officers, trustees, and representatives (in their official and individual capacities) from any and all liability whatsoever for any and all damages, losses, injuries or illnesses, including death, to persons or property or both, including but not limited to any claims, demands, actions, causes of action, damages, costs, expenses and attorney’s fees, which arise out of, during or in connection with my child(ren)’s participation in MHABC’s programs.
I agree the General Liability Release above is intended to be as broad and inclusive as permitted by the laws of the State of Indiana and if any portion is held to be invalid, it is agreed the balance of the release will continue in full force and effect.
In signing the Release, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provisions, that I understand it affects my legal rights and those of my child (or children), that it is a binding agreement, and that I have signed it knowingly and voluntarily.

Electronic Signature*