#UtahCNR Application 2018

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Participant First & Last Name *

Parent/Guardian First and Last Name *

Participant Date of Birth *

Please enter in MM/DD/YYYY format.

Parent/Guardian Primary Phone Number *

Please enter in ten-digit format: (801) 555-5555

Parent/Guardian Secondary Phone Number

Please enter in ten-digit format: (801) 555-5555

Parent/Guardian Mailing Address *

Parent/Guardian Email Address *

How did you hear about Camp Neuro Revolution? *

What is the level of participation we can expect from your child? *

This helps staff, at CNR, to know how to best prepare for and accomodate your child and their needs.

My child can participate fully and independently, both day and night.

My child can participate with some assistance and guidance, both day and night

My child can participate during the day but not at night.

My child can participate with the stipulation of 24 hour one-on-one assistance.

Tell us how we can best assist and guide your child, if necessary.

Do you have any concerns with your child staying overnight at Camp? Please explain.

If your child is unable to stay overnight, are you willing to transport them to and from the National Ability Center for the duration of Camp?

Please note, the Epilepsy Association of Utah and Camp Neuro Revolution are not responsible for costs of transportation or lodging outside of the National Ability Center.

If your child needs 24 hour assistance, are you willing to stay with them during the day and transport them at night?

Critical Information *

Camp Neuro Revolution (CNR) starts on the afternoon of Wednesday, June 18th and ends on the early afternoon of Thursday, June 21, 2018. CNR is located at the National Ability Center (NAC) in Park City, Utah. Please make note of this information. It is required that parents/guardians check their child in at the NAC on 6/18/18 and pick up their child on 6/21/18 at the NAC, unless other arrangements are made with the Director. Prepare to make any necessary accommodations. Upon an applicants acceptance registration forms are provided, which are due by 6/8/18 . Also, upon an applicants acceptance, a $50 registration fee is required. While the cost of camp is $450, scholarships are available, based upon need. Payment of registration fee and any other donation is due by 6/15/18. Please indicate below that you understand the listed expectations on transportation, fees, scholarships and time of duration for your participant.

Yes, I fully understand the information above.

No, I do not fully understand the information above. I will contact the Director for clarification.

Other:

Any Comments, Questions, Concerns? *

Please utilize this space to voice any concerns you may have, or may want to bring to the Director's attention. Otherwise, make note of the following information and feel free to email the EAU's Executive Director, Nicole Young, at info@epilepsyut.org, if you need any other information. Remember, this form is not considered full registration for your child. The application is due by May 11, 2018. You will be notified, via email, within the last week of May about the status for your child's application. Please note, if your application is not received by midnight on May 11, 2018, your child's application may not be accepted.

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