English Camp Neeka Registration 2025

CAMP NEEKA INFORMATION

Filling out this form does not ensure enrollment into Camp Neeka. Enrollment is based on first come first serve and best fit for services.

Camp Neeka Overview:

Camp Neeka supports campers who need more structure than a typical camp experience would provide. Our campers tend to have diagnoses like anxiety, depression, autism, trauma, adjustment disorder etc. We tend to enroll children who are struggling managing big reactions/big feelings towards "small" issues, struggling with negative thought patterns, or needing support with social skills. Our camp curriculum is CBT/DBT based, supporting our campers with coping skills, psycho education, and other strategies for working through big feelings, unknown situations etc.

Campers can only participate in one program due to billing and curriculum purposes.

Waukegan Camp:

When:June 2nd-June 27th from 9am-3pm

Where: Oakdale Elementary School (Pending confirmation)

Ages: 7-13 years old, Empowerment & Leadership Program: 14-16yrs

Northbrook Camp:

When: July 7th- August 1st from 9am-3pm

Where: Northbrook Junior High School

Ages: 7-13 years old, Empowerment & Leadership program: 14-16yrs

REGISTRATION FORM

Step 1: CAMPER BACKGROUND

You must complete a registration form for each child attending Camp Neeka
Camp Neeka Location: (Choose one)*

WaukeganNorthbrook
Years attended Camp Neeka: (Choose one)*

First Year1-23-56 or more
Camper Information:
Name *
First and Last Name
Chosen Name *
if applicable
Age*
Grade*
Gender*
Pronouns*
Other family members/friends attending Camp Neeka

If Yes, please provide names below.
Names
Any information or requests staff need to know about this relationship
Cargiver Information:
Name*
Phone*
Email*
Relation to Camper*

CAMPER PICK UP INFORMATION FORM

Please provide the contact information of all adults allowed to pick up the camper. If this information changes, please inform a Camp Neeka counselor.
Name*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relation*
Name
Phone Number
Please enter a valid phone number.
Email
Relation
Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relation
Name
Phone
Email
Relation
If your camper is 13 years old or older and will not be picked up, please click the box acknowledging permission and provide details of the transportation below:
I provide permission for my camper to transport themselves to and from Camp Neeka
Please initial
Please provide type of transportation (click all that apply)

BikeWalkTrainOther

Step 3: Insurance Information

Please complete insurance and financial information to ensure that Josselyn can provide the most accurate cost estimate for Camp Neeka

Please look over Camp Neeka's estimated billing structure below. Reminder, numbers may change based on insurance plan.

Payers	Client Fees	Payment Due
Self-Pay	$3000/Entire Camp	During Registration-before camp starts
Private Insurance	$2000/Entire Camp + Group Therapy: Co-pay/visit, $50 Max/visit, $250 Max/week	$2,000 collected during registration-before camp starts Group Therapy processed weekly (Monday) with credit card on file
Medicaid	$0	Bill to Medicaid
Scholarship	$0	Client needs to apply to be considered and needs to meet the qualifying criteria.

Please click the box below that connects to your current payment method for Camp Neeka: (choose 1)
Private Insurance
Private: Requires $2,000 due up front
Primary Coverage
Policy Holder Name
Policy Holder Date of Birth

MonthDayYear
Date
Payer Name
Payor Phone Number
Policy Number
Group Number
Secondary Coverage
Policy Holder Name
Policy Holder Date of Birth

MonthDayYear
Date
Payer Name
Payor Phone Number
Policy Number
Group Number

County Care/Medicaid
County Care/Medicaid
Policy Holder Name
Policy Holder Date of Birth

MonthDayYear
Date
RIN Number
INSURANCE CARD UPLOAD

Upload a copy of current insurance card(s)
Cancelof
SELF PAY
Self-Pay: Claims will contact client to initiate payment for $3,000 prior to the first day of camp.
SCHOLARSHIP OPPORTUNITY
Apply for a Scholarship (click one)*

YesNo
If yes, please Upload your 2024 Tax Forms & Two most recent pay stubs.

Cancelof

SERVICES INFORMATION
Client of Josselyn (click one that applies)*

YesNo
Therapists Name: (Last Name, First Name)
Day/Time of Weekly Therapy Appointment
Does your camper see a provider outside of Josselyn:*

YesNo
If yes, please provide the Organization/Company

MEDICAL INFORMATION

Please be sure to list all medical conditions, medicine, and allergies your child may have on the registration form. However, Camp Neeka staff are prohibited from administering any medications to your child.
Medical Needs/Allergies (click one that applies)*

YesNo
If yes, please include: The type of medication, time of day it is taken, special instruction for taking medication.
Other medical concerns co-occurring with mental health challenge (click all that apply)

EatingExerciseChewing/biting at skinOther
POLICIES WAVIERS
Initial*
Initial*

WHAT COMES NEXT?

Any logistical questions, check out our Camp Neeka website Camp Neeka - Josselyn for information regarding timing, dates, location, curriculum, SEL supports etc.

NEXT STEPS: If you are not a Josselyn client:

Someone from Josselyn's Camp Neeka will be looking over your registration form to ensure your child is a good fit for Camp Neeka. (Depending on space and availability at your requested camp location)

If your child is a good fit, someone from Josselyn's assessment team will reach out to set up a 15 min virtual intake assessment, within two weeks of submitting your application.

What is this assessment? Discussion with a Josselyn clinician, reviewing your application, asking any further necessary questions, and completing a camp Neka treatment goal. This is necessary to enroll your child into Josselyn's system. Your child will not need to be present during this assessment.

If we feel your child is not a good fit, someone from the Camp Neeka team will give you a phone call to discuss further.

NEXT STEPTS: If you are a Josselyn client:

Someone from Josselyn's Camp Neeka team will be looking over your registration form to ensure your child is a good fit for Camp Neeka. (Depending on space and availability at your requested camp location)

If your child is a good fit, Maggie Nash will email you and your Josselyn therapist to confirm registration has been received and accepted.

If your child is not a good fit, Maggie Nash will set up consultation with Josselyn therapist and provide necessary next steps.

Reminder: Filling out this form does not ensure enrollment into Camp Neeka. Enrollment is based on first come first serve AND best fit for services. If Camp Neeka is full, someone from our team will let you know and ensure the application is saved for our waitlist or next year's enrolment.
I acknowledge that the information provided is true to the best of my knowledge, I also understand that any information given that is willfully dishonest can result in refusal of this application or dismissal from Camp Neeka.
Should be Empty:

CAMP NEEKA INFORMATION

Step 3: Insurance Information

Please click the box below that connects to your current payment method for Camp Neeka: (choose 1)

Private Insurance

County Care/Medicaid

SELF PAY