Camp Geronimo Application 2019
Thank you for your interest in Camp Geronimo. This application is required for all children who wish to attend the camp. Camp Geronimo is an inclusive camp for children ages 6 – 12 years old. All activities are led by a Licensed Physical Therapist. Space is limited to 16 children per weekly session, Monday through Friday 9:00am – 2:00pm. We ensure a minimum 1:1 counselor to child ratio. There will be a camp nurse present each week.

Your camper’s preferred week(s) of camp will be reserved upon receipt of this application, but acceptance of campers is always at the discretion of the Camp Director.

New campers are required to visit us for an onsite interview at The Barn at Spring Brook Farm.
Please call The Barn to schedule your interview at 610-793-1037.

You must also mail us a copy of Health History Forms 1 & 2 with the signed consent/signature pages.
Health History Forms must be submitted by May 15, 2019. There is a checklist for your convenience to ensure that you have all of the documents completed for your camper to participate in camp.

*Health History Form 2 must be signed by a physician- please ask your doctor what their policy is on health forms--you may need to schedule a well-visit in order for the form to be completed. Please allow enough time to complete these forms. Your child will not be able participate in camp without all documents being completed, including the Physician Form.

Forms and checklist can be found at:
http://springbrook-farm.org/programs/camp-geronimo-application-2019/

Email address *
GENERAL INFORMATION
Child's Name *
Your answer
Nickname
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address (Street, City, State, Zip) *
Your answer
Home Phone (xxx-xxx-xxxx) *
Your answer
Child lives with:
Your answer
School your child attends:
Your answer
School Duration
Has your child ever participated in a summer camp program? *
Has your child ever participated in Camp Geronimo? *
How did you find out about Camp Geronimo?
Your answer
T-Shirt Size? (Please include child or adult with sizing preference)
Your answer
How many weeks of camp would you like your child to attend?
Please rank the week(s) you would like your child to attend Camp Geronimo in order of preference:
FIRST choice is required. If you want your child to attend more than 1 week of camp, please complete the additional choice options for the respective number of weeks. We recommend selecting at least 2 choices in case your 1st choice of week is not available.
FIRST CHOICE: *
SECOND CHOICE:
THIRD CHOICE:
FOURTH CHOICE:
FIFTH CHOICE:
SIXTH CHOICE:
PARENT AND GUARDIAN INFORMATION
Parent/Guardian Name *
Your answer
Relation to Child *
Your answer
Address (Street, City, State, Zip) *
Your answer
Home Phone (xxx-xxx-xxxx)
Your answer
Cell Phone (xxx-xxx-xxxx)
Your answer
Work Phone (xxx-xxx-xxxx)
Your answer
E-mail
Your answer
Preferred method of contact:
Parent/Guardian Name
Your answer
Address (Street, City, State, Zip)
Your answer
Work Phone (xxx-xxx-xxxx)
Your answer
Cell Phone (xxx-xxx-xxxx)
Your answer
Home Phone (xxx-xxx-xxxx)
Your answer
E-mail
Your answer
Preferred method of contact:
EMERGENCY CONTACTS
Please include 2 other people we may contact in an emergency if we are unable to reach the Parents/Guardians listed above.
Emergency Contact 1- Name *
Your answer
Phone (xxx-xxx-xxxx) *
Your answer
Address (Street, City, State, Zip)
Your answer
Relationship to child *
Your answer
Authorized to release child to: *
Emergency Contact 2- Name *
Your answer
Phone (xxx-xxx-xxxx) *
Your answer
Address (Street, City, State, Zip)
Your answer
Relationship to child: *
Your answer
Authorized to release child to: *
MEDICAL AND HEALTH HISTORY
There are 2 additional health history forms that must be completed and mailed to:
The Barn at Spring Brook Farm
360 Locust Grove Rd.
West Chester, PA 19382

These forms can be downloaded from: http://springbrook-farm.org/programs/camp-geronimo-application-2019/

Physician's Name
Your answer
Physician's Phone (xxx-xxx-xxxx)
Your answer
What is your child's primary disability category?
Your answer
What is your child's secondary disability category(s)?
Your answer
Does your child have allergies?
If yes, please check the appropriate boxes below:
Please describe allergy and reaction:
Your answer
ASSISTIVE DEVICES
Please indicate if your child uses any of the following: *
Required
DIET AND NUTRITION
Please select all that apply: *
Required
Please describe any diet and nutritional needs:
Your answer
BATHROOM BEHAVIORS
Is your child toilet trained?
Does your child require diapers or pull-ups?
Does your child need prompting to use the bathroom?
How often for prompting?
Your answer
MEDICATIONS
Medication includes vitamins and natural remedies. We REQUIRE that all medications are in the original pharmacy container with the camper’s name and physician’s prescription. Please provide enough medication to last the entire time while at camp.

If your child has an emergency plan that includes as-needed (PRN) medications, please include the emergency plan with the medical forms.

Please select the appropriate statement: *
Medication Policy
1) I will bring my child’s medication in its original container with my child’s name & administration instructions and will hand-deliver to the camp nurse.

2) I assert that I have provided accurate and truthful information to the best of my ability including any information the staff should be made aware of on this application.

Medication Policy Acknowledgment *
Required
Supplemental health history forms will be required from all campers!
Please download Health History Forms 1 & 2 from The Barn website at:
http://springbrook-farm.org/programs/camp-geronimo-application-2019/
Parent/Guardian Name (this will act as your confirmation for the above statements):
Your answer
TELL US MORE ABOUT YOUR CHILD
If your child requires a TSS, PCA or nurse while in school, then that TSS, PCA or nurse must be present with your child at camp. If staffing is a problem, please contact The Barn to discuss your situation. If your child will be accompanied by support staff such as a TSS or PCA, please provide the person’s name, title, and agency.
Does your child have a TSS, PCA or nurse at school? *
If yes, please specify (include name, title, and agency of TSS or PCA that will accompany child to camp):
Your answer
Please describe your child’s disability or special needs (behavior, diagnosis, etc):
Your answer
Does your child have a behavior plan? *
What type of plan(s)? Select all that apply.
If you answered 'yes' to behavior plan, please include a copy of the plan with the health history forms.
Mail to:
The Barn at Spring Brook Farm
360 Locust Grove Rd.
West Chester, PA 19382
Does your child elope?
Are there certain situations that result in elopement?
Your answer
Does your child have mood swings?
If yes, what are the triggers and resulting behaviors?
Your answer
Please share any information that you believe would assist us in better knowing your child including, special interests, likes/dislikes, etc.
Your answer
How do you hope your child will benefit from his/her camp experience?
Your answer
SENSORY SURVEY
Does your child like to move a lot or do they like to be still?
Your answer
Do some sounds bother your child?
If yes, which sounds?
Your answer
Does your child like to touch different materials or do they often avoid touch and use tools?
Your answer
Is your child a picky eater or do they tend to stuff their mouths?
Your answer
Does your child have a strong reaction to smells?
Your answer
Does your child enjoy physical contact or do they shy away from it?
Your answer
Cancellation and Refund Policy
If you cancel your child’s camp session up to 30 days prior to the first day of camp, you will receive a full refund. Campers cancelling within 30 days of the start of camp must provide a note from their healthcare provider stating that they may not attend camp due to health reasons in order to receive a full refund.
Cancellation Policy Acknowledgment *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service