Apply for a camp scholarship here! "*" indicates required fields Δ PhoneThis field is for validation purposes and should be left unchanged.Camper InformationCamper Name* First Last Preferred Name (if different)Date of Birth* MM slash DD slash YYYY School NameGrade Entering Fall 2026*Pre-K - Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDietary Restrictions Dairy Free Gluten Free Peanut Vegan Vegetarian Please include additional services needed (ex: interpreter)Parent/Guardian Information(will serve as emergency contact & authorized pick-up person)Parent/Guardian Name* First Last Relationship to Camper*Primary Phone*Alternate PhoneEmail* For registration confirmation and camp updates.Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional Emergency Contacts & Authorized Pick-Up PersonsAdditional Contact Name - 1 First Last Additional Contact Phone - 1Relationship to Camper - 1Additional Contact Name - 2 First Last Additional Contact Phone - 2Relationship to Camper - 2CampPre-K Inspire Health Kids Mini-Camps (4 and 5-year olds) Dates: June 23rd, 24th, and 25th Time: 8:30am-11am Location: John Parolo Education Center Cost: Free to attend, spots are limited! Description: Designed for our youngest learners, this mini-camp introduces health and wellness through play, movement, and hands-on fun. Campers will explore healthy habits and meet friendly healthcare helpers—all in a fun, welcoming environment that builds curiosity and confidence. Join us for one day or stay for all three-each day features new activities and topics. Please select the day(s) your camper will be attending* Tuesday, June 23rd Wednesday, June 24th Thursday, June 25th Inspire Health Kids Camp (Entering 1st -- 3nd Grade) Dates: June 30th-July 2nd Time: 8:30am-3pm Location: John Parolo Education Center Cost: $120 Description: Young campers will explore the world of health and wellness through fun, hands-on activities designed for early learners. With the help of local healthcare professionals, students will get a playful introduction to fields like medicine, dentistry, and more. This year, campers will field trip to Misty Morning Farms with our dietitian to learn how food grows and supports healthy bodies. Campers will also observe an instructor conducting a mammal dissection.Inspire Health Kids Camp (Entering 4th -- 6th Grade) Dates: July 14th – 17th Time: 8:30am-3pm Location: John Parolo Education Center Cost: $160 Description: Campers will explore the world of healthcare through interactive workshops, creative projects, and engaging lessons led by CHC/SEK health professionals—including physicians, dentists, physical therapists, and more. They’ll discover how different health careers work together to care for patients—and may even find inspiration for a future career! Along the way, campers will visit Misty Morning Farms to learn about nutrition from the ground up, spend time at Orion Ranch Sanctuary to explore how connecting with animals and nature supports our nervous system, and experience a day on PSU’s campus alongside nursing students and other health science learners. Campers will also participate in small-group mammal dissections.Inspire Health Academy (Entering 7th -- 12 Grade) Dates: July 21st – 24th Time: 8:30am – 3pm Location: John Parolo Education Center Cost: $160 Description: Designed for middle and high school students interested in healthcare, this academy-style camp offers an in-depth look at medical, dental, and behavioral health careers. Campers will learn from multi-disciplinary professionals through hands-on activities, clinical simulations, and Q&A sessions—gaining insight into real-world care and career pathways. Highlights include visits to Misty Morning Farms to explore nutrition and food systems, time at Orion Horse Sanctuary to understand how connection with animals and nature supports the nervous system, and a day on PSU’s campus alongside students in nursing and other health science programs. Campers will also complete a guided mammal dissection alongside a physician.Pre-K Inspire Health Kids Mini-Camps -- 4 and 5-year olds Price: Inspire Health Kids Camp (Entering 1st -- 3rd Grade) Price: Inspire Health Kids Camp (Entering 4th -- 6th Grade) Price: Inspire Health Academy (Entering 7th -- 12th Grade) Price: Waivers & AuthorizationsCamp Participation Waiver: I understand by Community Health Center of Southeast Kansas, Inc. (CHC/SEK), Inspire Health Foundation, Inc. (IHF), and its agents will take reasonable safety precautions during camp activities. I acknowledge the inherent risks, including physical and emotional challenges, and agree to follow all safety instructions. I accept full responsibility for any injury, death, or property damage that may occur due to camp activities or actions by myself or others. I release CHC/SEK and IHF, their staff, contractors, and affiliates from all liability related to myself and/or my child’s participation in Inspire Health Camp.Health & Medication Information: If your child has allergies and medical needs camp staff should be aware of please complete the medication and allergy form to confirm that the health information provided is complete and accurate. I understand that withholding health details may risk my safety, my child’s safety, or others’ and release CHC/SEK and IHF from liability if such information is not disclosed. I agree to use my personal insurance for any accidents. If medical treatment is needed and a parent/guardian cannot be reached, I authorize CHC/SEK and IHF to seek emergency care for my child, including ambulance transport. I also permit camp staff to share necessary health information with medical providers.I understand and agree with the above statements regarding participation, health, and medications* I Agree Photo Release:I give my permission to CHC/SEK, IHF, and the Health Resources and Services Administration (HRSA) and any other U.S. Government agency to use the photographic/video image(s) of myself or someone for whom I have legal responsibility. The image(s) may be used for any official publication, in print or digital form. I further give HRSA full rights to use these images in other official U.S. Government publications at any time. I also agree that HRSA may provide these images to the media as part of U.S. Government business. I waive any right to editor approve the finished product in which the image(s) is used.Photo Release* I give my permission to CHC/SEK, IHF, and the Health Resources and Services Administration (HRSA) and any other U.S. Government agency to use the photographic/video image(s) of myself or someone for whom I have legal responsibility. I do not give permission to CHC/SEK and HRSA to photograph or record my child. Transportation (for 1st through 12th graders only)* I give permission for my child to travel to and from Orion Ranch Sanctuary(4th-12th graders only), Misty Morning Farms (1st-12th graders), and Pittsburg State University (4th-12th graders only) in a CHC/SEK vehicle driven by CHC/SEK transportation staff. I do not give give permission to CHC/SEK to transport my child and will opt out of the field trips to Orion Ranch Sanctuary (4th-12th graders only), Misty Morning Farms (1st-12th graders), and PSU (4th-12th graders only). I understand my child may re-join camp after the visit or opt out of the entire day. Signature of Parent/Guardian*Payment InfoIs this camper a family member of a CHC/SEK employee?* Yes No CHC/SEK Employee Name* First Last CHC/SEK office location*Gift a partial or full camp scholarship Enter the amount you’d like to contribute toward a partial or full scholarship above.Will you help cover the transaction fees?* Yes No Processing Fee Price: $0.00 CHC/SEK Employee Discount $0.00 Subtotal $0.00 Used for processing fee calculation only.Total Payment Options* Pay online I have requested a camp scholarship Pay in person Pay OnlinePayPal CheckoutCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name