2018 Camp Kaleidoscope Family Application
Camp Kaleidoscope is a magical experience for families with children experiencing autism. It is a unique opportunity to network and have fun and relax in a nonjudgmental and stress reduced setting.

The dates for Camp K 2018 are Saturday, June 23 - Tuesday, June 26, 2018.

Our camp fees are on a sliding scale, so you may pay what you feel you can afford within the sliding scale range we have set up between $500-$250 per person attending camp. That means that the fee for a family of 4 would be $2000 to $1000.

If you cannot afford to pay the bottom of the sliding scale we have a campership application that you will need to submit before being considered.

If you have any questions about Camp Kaleidoscope or our fees please visit our website, www.cgcvt.org, email us at cgccampkaleidoscope@gmail.com or call Carole at 802-881-8278.

Items with a red asterisk are required. Don't forget to click submit. Thank you!

Family Name *
(e.g The Timmons Family)
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number *
Your answer
Best Time to be reached by phone *
Your answer
Email Address *
Your answer
Lodging Option *
* Cabin usage is included in your camp fees. If your family has a medical need or is paying the top of the sliding scale, feel free to apply for a space in the Lodge, pricing is as follows: $250/ 4 person room, $175/ 2 person room, $160/4 person room w/o bath.
Need for room in the Lodge *
Will you still be able to attend camp even if there is no space available in the Lodge? Please feel free to contact us if you have questions about this.
Is there any reason we should avoid placing your family in a cabin/room with a lofted bed or bunk bed? *
(if no, please state so)
Your answer
Adults coming to Camp
Please fill out all pertinent information about all adults and young people attending Camp Kaleidoscope.
Adult #1 Name *
Your answer
M/F
Your answer
DOB
Your answer
Adult #1 Dietary Restrictions? *
Please answer none if there aren't any.
Your answer
Adult #1 Medical needs/Allergies *
Please answer none if there aren't any.
Your answer
Adult #2 Name
Your answer
M/F
Your answer
DOB
Your answer
Adult #2 Dietary Restrictions?
Please answer none if there aren't any.
Your answer
Adult #2 Medical needs/Allergies
Please answer none if there aren't any.
Your answer
Children coming to camp
Please fill out all pertinent information about all young people attending Camp Kaleidoscope. If this is your first time at Camp K please tell us a little about your camper(s) with ASD.
Child #1 Name *
Your answer
M/F *
Your answer
DOB *
Your answer
Child #1 Dietary Restrictions? *
Please answer none if there aren't any.
Your answer
Child #1 Medical needs/Allergies *
Please answer none if there aren't any.
Your answer
Camper with ASD? *
Required
Where does your child go to school? *
Required
Tell us about your child with ASD *
What do they enjoy, what is difficult for them, what kind of year have they had, etc
Your answer
Does your child (#1) work with a PCA? *
We strongly encourage you to bring a PCA to camp with you if your child is used to having someone. PCAs can attend Camp K free of charge.
Your answer
Child #2 Name
Your answer
M/F
Your answer
DOB
Your answer
Child #2 Dietary Restrictions?
Please answer none if there aren't any.
Your answer
Child #2 Medical needs/Allergies
Please answer none if there aren't any.
Your answer
Camper with ASD?
Where does your child go to school?
Tell us about your child
What do they enjoy, what is difficult for them, what kind of year have they had, etc
Your answer
Does your child (#2) work with a PCA?
We strongly encourage you to bring a PCA to camp with you if your child is used to having someone. PCAs can attend Camp K free of charge.
Your answer
Child #3 Name
Your answer
M/F
Your answer
DOB
Your answer
Child #3 Dietary Restrictions?
Please answer none if there aren't any.
Your answer
Child #3 Medical needs/Allergies
Please answer none if there aren't any.
Your answer
Camper with ASD?
Where does your child go to school?
Tell us about your child
What do they enjoy, what is difficult for them, what kind of year have they had, etc
Your answer
Does your child (#3) work with a PCA?
We strongly encourage you to bring a PCA to camp with you if your child is used to having someone. PCAs can attend Camp K free of charge.
Your answer
Child #4 Name
Your answer
Gender
Your answer
DOB
Your answer
Child #4 Dietary Restrictions?
Please answer none if there aren't any.
Your answer
Child #4 Medical needs/Allergies
Please answer none if there aren't any.
Your answer
Camper with ASD?
Where does your child go to school?
Tell us about your child
What do they enjoy, what is difficult for them, what kind of year have they had, etc
Your answer
Does your child (#4) work with a PCA?
We strongly encourage you to bring a PCA to camp with you if your child is used to having someone. PCAs can attend Camp K free of charge.
Your answer
Your family
If this is your first time applying for Camp Kaleidoscope, please take this opportunity to tell us about you and your family. If you have been to Camp K before, please let us know what you've been up since you were with us last!
How would Camp K be helpful to you and your family? *
Your answer
Has your family been to Camp K before? *
Required
Will you be counting on a campership in order to attend Camp Kaleidoscope? *
Camp K rates are based on a sliding scale ($250-$500) per person. Campership monies are available to those who cannot pay the bottom of the scale. A campership application will need to be completed.
Required
If so, how much would your family be capable of paying? *
Your answer
THANK YOU!
Given the overwhelming popularity of Camp Kaleidoscope and the limited number of spots there is often a waiting list for the program. The staff of Common Ground Center make every effort to fit as many families as possible into the program.

The first round of acceptances will be issued in late January 2018 and, the second round of acceptances will be issued February 28th 2018.

If you are not accepted during the first round, your application will be entered into the second round.

Accepted families will have 48 hours to respond once they are notified of their selection. Please make sure you have left us accurate contact information.

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