Camp Parkview Camper Application

Parkview Services | Affordable Housing | Camp Parkview | Group Home | Stepping Out For Fun | Homeownership

* All fields are required except as noted.

* Camper name:

* Date of Birth:

Nickname (Not required):

* Gender:

Male Female

* Address:

* City:

* State:

* Zip:

* Telephone:

* Email address (Enter N/A if none):

* Name of person filling out this form:

* Relationship to Camper:

* Phone of person filling out this form:

* Email Address of Person filling out this form:

* Care/Residential Support Provider (Enter N/A if there is none):

* Relationship to Camper:

* Address: (If same as camper's address, enter "same"):

* City:

* State:

* Zip:

* Phone of Care/Residential Support Provider:

* Email Address of Care/Residential Support Provider:

* Legal guardian (Enter N/A if there is none):

* Telephone:

* Guardian email (Enter N/A if none):

* Required only if there is a guardian.

* Physician:

* Telephone:

* 24-Hour Emergency contact:

* Telephone:

* Relationship:

* Can Camp Parkview use photos or videos (in print or digital form) of this camper for future
outreach or fundraising? Yes No
* Can Camp Parkview print this camper's name and address on the camp roster, which is given to all the campers and counselors at the end of the camp session? Yes No
* Can Camp Parkview use any artwork made and donated by the camper for use on the annual Camp Parkview T-shirt or for fundraising purposes? Yes No
* What is the T-shirt size of the camper? Small: Medium: Large: XLarge: XXLarge:
* Did you attend Camp Parkview last summer? Yes No
* What has been the camper's previous camp experience?

Camper Info

* Height * Feet: * Inches: * Weight: * Age:

* Hair Color: * Eye Color:
* Type of disability (please be specific):
* List all types of physical aids you use (e.g., wheelchair, cane, hearing aid,
dentures, prosthetic braces, helmet, glasses, etc) or N/A if none are used:
* Please describe this camper's ability to participate in small and large group activities without 1:1 supervision. (Describe or N/A)
* If this camper becomes upset, what is the best way to handle the situation? (Describe or N/A)
* If this camper has problems with incontinence, please describe a strategy to best meet his/her needs, including night time protection. (Describe or N/A)

Do you have any of the following conditions?

Yes No	* Allergy to foods	Yes No	* Heart condition
Yes No	* Allergy to drugs	Yes No	* Hernia
Yes No	* Allergy to bee stings	Yes No	* Hypoglycemia
Yes No	* Appendicitis	Yes No	* Incontinence
Yes No	* Arthritis	Yes No	* Menstrual difficulties
Yes No	* Asthma	Yes No	* Mental Health Issues
Yes No	* Behavioral disorders	Yes No	* Orthopedic problems
Yes No	* Circulation problems	Yes No	* Respiratory condition
Yes No	* Contagious diseases	Yes No	* Seizures
Yes No	* Diabetes	Yes No	* Skin condition
Yes No	* Difficulty keeping warm	Yes No	* Sinus condition
Yes No	* Difficulty adjusting to cold	Yes No	* Speech difficulties
Yes No	* Digestive problems	Yes No	* Ulcers
Yes No	* High/Low blood pressure	Yes No	* Vision loss
		If yes, describe vision loss:
Yes No	* Hearing loss	Yes No	Other
If yes, describe hearing loss:		If yes, describe other:

Please thoroughly explain any items marked "Yes" including how camp counselors
should treat each condition, what to do in an emergency,
and describe the symptoms of the condition.
If none were marked "Yes", enter "N/A".

Thank you for applying to Camp Parkview!