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Camper Application 2025
Please fill out this form entirely after completing the camper pre-registration. 
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Participant Information
Name *
Full Address (street, city, state, zip)  *
Phone Number *
Email *
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Parent/Guardian Information/Emergency Contact
Name and Relationship *
Phone (home/cell/work) *
Address (if different from camper) 
Who should we contact if we are unable to reach you in case of an emergency?
Name, relationship and phone number
 *
Education/Work Information
School Attending/Attended *
Current Grade Level or Grade Level Completed  *
Reading Level  *
Math Level  *
Place of Employment (if applicable)
Medical Information
Primary Medical Diagnosis *
Secondary Medical Diagnosis
Primary Insurance Provider *
Please list all medications you currently take and dosages *
Please list any environmental or food allergies *
Do you have seizures?  *
If yes, please describe the characteristics
Do you smoke?  *
If yes, how many cigarettes per day? 
Do you drink alcohol?  *
If yes, how much and how often? 
Please explain any PHYSICAL limitations you may have
Please explain any VISUAL impairments you may have
Please explain HEARING impairments you may have
Please explain any SPEECH impairments you may have
Do you have any inappropriate behaviors?  *
If yes, please describe in detail
Have you ever been denied participation in any programs due to aggressive behaviors?  *
If yes, please describe in detail 
Do you receive psychological counseling?  *
If yes, what is the name/address of your current counselor? 
Are you taking medication for depression or behaviors? *
If yes, please list the medication and dosage
Expressive/Receptive Information
What is your primary means of communication?  *
Required
Please select which best describes your speech *
Which best describe you when you are not understood? *
Do you have any difficulty understanding other's speech?  *
Do you initiate communication with others?  *
Do you use a communication device?  *
If yes, please list the type of equipment used
What word best describes your nutritional habits?  *
How would you describe your overall health? *
Please describe your method of mobility *
Required
Do you have good balance? *
If no, please explain
Do you have any of the following?  *
Required
Please explain any upper extremity contractures
Please list any medication allergies
Please explain any other medical or emotional conditions we should be aware of
Activities of Daily Living
Please select all activities that you are able to perform without assistance *
Required
If no activities can be performed in the above areas, please explain why not and how this function is performed for you. 
Do you have an aide?  *
If yes, will your aide be accompanying you to the program? 
Clear selection
Do you receive services from your local community services board?  *
If yes, please provide the name of your case worker, phone number, and city you receive services from
Do you have any difficulty chewing or swallowing? 
Clear selection
If yes, please explain 
Do you use your right hand or left hand?  *
Please describe your manual dexterity *
Social Interaction Information
What are your favorite social activities?  *
Who are the significant people in your life? *
Do you have any hobbies or collect any items of interest?  *
Do you get along with others?  *
If no, please explain
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