Camp Resilience Application
Please complete this form, verify its accuracy, and then click the Submit button. This information assists us in selecting participants who can successfully complete and benefit from a Camp Resilience session and in planning appropriate activities. Your participation during Camp Resilience will afford you the opportunity to engage in activities that are physically demanding and emotionally draining. It is important that you accurately complete this form to maximize the benefits of Camp Resilience.

By submitting this form, you are confirming that you have provided all the information that is requested and that you have no medical or other restrictions that you have not disclosed that would interfere with your participation.

After the review of the application, the PRLI reserves the right to request that you provide a release of information form to your physician or therapist so we can get confirmation that you are physically, emotionally and psychologically able to participate in a Camp Resilience session.

Camp Resilience Event Applying For:
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Who referred you to Camp Resilience?
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First Name
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Last Name
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Address
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City
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State
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Phone
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E-mail
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Branch of Service
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Dates of Service
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Date of Birth
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Height
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Weight
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Do you have a service related disability?
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Do you have a service animal?
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List All Known Allergies
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Have you been treated by a Physician/Therapist in the past 12 months? If yes, why?
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Check any medical/psychological conditions below that apply to you
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Remarks
Explain any medical conditions checked above
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List all current medications below with the dosage, frequency and reason.
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Do you require Assistive Devices? If yes, please explain
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Are you independent with mobility? If no, please explain what assistance is needed/desired.
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What else, if anything, should we know about you to support your participation in this program (example: "I fatigue easily and would appreciate opportunities to sit whenever possible", "I have limited use of my right arm")
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Briefly discuss the issues you are currently dealing with and how you think Camp Resilience will help you better deal with these issues.
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