Summer Camps 2024:Guys&Girls Night Out Permission Form
Guys and Girls' Night Out is a Community Respite Event. Free to IO, Level 1 or Self Waivers and Local Funding. This will be waiver funded. You will need an SSA and a Medicaid Number.
We need higher functioning Individuals who can go to the restroom on their own. No wheelchairs access at this time. 
The individual needs to dropped of at Oz (914 E. Tallmadge Avenue Akron, Ohio 44310) on Friday (Selected Date of the summer camp)
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Limited Seats available. We will be staying in Cabins at Rocky Fort Ranch private resort, Different activities for Guys and Girls.
Learning Nature Skills, Having a Gaming Battle contest at night, Air Hockey, Movies, Karaoke, Boating and a Pizza party and a lot more.
Individual's Name: *
Email address: *
Phone number: *
Complete Residential Address: *
Guardian's Full Name
Guardian's Email and Phone Number:
SSA Name: *
SSA Phone number
SSA Email address *
Medicaid Number: *
Emergency Contact Person and Phone Number
Do you need assistance with medication? *
Do you need a behavioral Support? If yes, Please explain. *
Select the Summer Camp you would like to attend. (You can attend more than one camps) *
Required
Please mention if you need any special accommodations  if you have any allergies.
Also, mention if you can used bathroom on your own. This information is important to have the staff ready.
The videos or picture taken during this event may be used for flyers, banners and newsletters etc. They may be shared with community for our upcoming events.
 *
YES
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