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Camp Parkview Camper Application
Sunday August 11th - Friday August 16th, 2013
Step 1 of 2 - Camper Contacts and Consents
50%
Application
must
be submitted by 11:59 PM April 30, 2013. Acceptance letters will be mailed by May 31, 2013.
Camper Name:
*
First
Last
Camper Nickname:
Camper Gender
*
Male
Female
Has camper attended Camp Parkview in the past?
*
No
Yes (Once before)
Yes (More than once)
What year did the Camper last attend Camp Parkview?
*
How many times has Camper attended Camp Parkview?
*
Camper Address:
*
Street Address
City
State / Province / Region
Zip / Postal Code
Camper Date of Birth:
*
Camper Phone:
*
Name of Residential Support Provider:
Care Provider or Residential Support Provider Contact Name:
*
First
Last
Care Provider Telephone:
*
Care Provider Email:
*
24 Hour Emergency Contact Full Name:
*
Emergency Contact Relationship to Camper
*
Emergency Contact Telephone:
*
Emergency Contact Email:
Does the camper have a legal guardian?
*
No
Yes
Legal Guardian Full Name:
*
Legal Guardian Contact Telephone:
*
Legal Guardian Email:
Physician Full Name:
Physican Emergency Telephone:
Comments or Clarifications (if any)
Camper Consents
Please answer yes or no to the following.
Can Camp Parkview use photos or videos of this camper for future outreach or fundraising?
*
Yes
No
Can Camp Parkview print this camper's name and address on the camp roster for distribution to campers?
*
Yes
No
Can Camp Parkview use artwork made by this camper for promotional materials or the future Camp T-shirts?
*
Yes
No
What is this camper's T-shirt size?
*
Small
Medium
Large
XLarge
XXLarge
Height:
*
Weight:
*
Hair Color:
*
Eye Color:
*
Type of disability (please be specific):
*
Please list all the physical aids you use (wheelchair, cane, hearing aid, dentures, prosthetic braces, helment, glasses, etc.):
*
Please describe the campers ability to cooperate and have fun in small and large groups without one-on-one supervision (our counselor-to-camper ration is 1:3)
*
Please describe positive strategies to use if the camper becomes upset:
*
If this camper has problems with incontinence please discribe strategies to avoid accidents both during the day and night including whether or not the camper wears night time protection.
*
Does this camper have any of the following conditions (check all that apply)?
*
Allergy to bee stings
Allergy to food (specify below)
Allergy to medications (specify below)
Arthritis
Asthma
Behavioral Disorders
Circulation Problems
Contagious diseases
Diabetes
Difficulty keeping warm
Digestive problems
Hearing Loss (describe below)
Heart condition
Hernia
High/Low blood pressure
Hypoglycemia
Menstrual difficulties
Orthopedic problems
Respiratory conditions
Seizures
Sinus condition
Skin condition
Speech difficulties
Ulcers
Vision loss
Other (specify below)
Please thoroughly explain each item checked above. Include how campl counselors should treat each condition, what to do in an emergency, and describe the symptoms of the condition. Please give us the most accurate and helpful information.
*
Name of the person filling out this application:
*
Telephone Number of person filling out this application:
*
Email of person filling out this application:
Name
This field is for validation purposes and should be left unchanged.
