2020 Camper Application Form
For Parents to Complete
Please note: you must also complete the Medical Application form in order for your child to attend camp.
Last Name: *
First Name: *
Nickname: *
Birth Date: *
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Child's Age: *
Gender *
Required
Grade in School: *
Child's Home Address:
Street: *
City: *
State: *
Zip: *
Who does your child live with? *
Relationship to Child: *
Parent's Name: *
Parent's Contact Info:
Home Phone: *
Work Phone: *
Cell Phone: *
Email Address: *
Emergency Contact:
Name: *
Home Phone: *
Work Phone: *
Cell Phone: *
Email Address: *
General Questions:
Has your child been a Camp Rainbow camper before? If Yes, when? *
Do you want to request a specific counselor? If yes, who?
What diagnosis qualifies your child for Camp Rainbow? *
When was your child diagnosed? *
Who is your child's Medical doctor? *
Doctor's Address:
Street: *
City: *
State: *
Zip: *
Office Phone: *
What does your child know or understand about his/her illness?
Please list your child's information:
Weight: *
Height: *
Shirt Size (please also specify if size is Child or Adult size): *
Does your child use: *
Required
Please explain any assistance that is needed for you child to walk or be ambulatory: *
Does your child need any unusual assistance with personal care needs? *
Has your child stayed away from home before? *
Does your child have any problems communicating with others? *
Please answer YES or NO to the questions below:
Please make extra comments as need in the text area provided at the end of this section. We want to know as much about your child as possible.
Are there any physical conditions to prevent your child from being in the swimming pool? *
Required
Any problems being in the sun or heat with proper precautions? *
Required
Are there any hearing or vision impairments? *
Required
Has your child had Chicken Pox? *
Required
Date of Disease or Vaccine: *
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What other medical treatments or procedures will the Camp Rainbow Nursing Staff need to provide the week of camp besides medications? (Examples; urinary cauterization, breathing treatments, Chest percussion, G Tube feedings, wound dressing changes) *
Does Camp Rainbow have permission to do the following?
Let your child ride horses with assistance? *
Required
Ride on a hay ride? *
Required
Ride in a boat? *
Required
Get a haircut from a professional hair stylist? *
Required
Ride on a motorcycle on Camp grounds with a biker? *
Required
Ride in a car if needing to leave the Camp grounds for some reason? *
Required
Ride in a jeep to go "MUDDING"? Safety belts are in the Jeeps. *
Required
Have a photo taken at Camp? *
Required
Be included on brochures, pictures, or television if chosen to do so? *
Required
Camp Pick-Up day is Saturday, June 13th at 9:00am. Who will pick up your child? *
Any known allergies to medications (Please list). *
Medication given to you child at home. List Medication Name, Amount Given, and How Often. *
Authorization and Electronic Signature
Terms and conditions: by checking the box thereby agreeing to the terms and conditions, I certify that I am the authorized parent(s) of the above named child, and agree for the child to attend the functions provided by Camp Rainbow from June 8th to June 13th, 2020. I/We release Camp Rainbow and its volunteers from any and all liability to my/our child as a result of transportation to and from the aforementioned Camp engagement of activities during Camp; use of materials, buildings, and/or environment; and specifically give my permission for my/our child to attend this function.
Please type your name: *
Date: *
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*** Please note: you must also complete the Medical Application form in order for your child to attend camp. ***
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