2019 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: *
Your answer
First Name: *
Your answer
Nickname: *
Your answer
Birth Date: *
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Child's Age: *
Your answer
Gender *
Required
Grade in School: *
Your answer
Child's Home Address:
Street: *
Your answer
City: *
Your answer
State: *
Your answer
Zip: *
Your answer
Who does your child live with? *
Your answer
Relationship to Child: *
Your answer
Parent's Name: *
Your answer
Parent's Contact Info:
Home Phone: *
Your answer
Work Phone: *
Your answer
Cell Phone: *
Your answer
Email Address: *
Your answer
Emergency Contact:
Name: *
Your answer
Home Phone: *
Your answer
Work Phone: *
Your answer
Cell Phone: *
Your answer
Email Address: *
Your answer
General Questions:
Has your child been a Camp Rainbow camper before? If Yes, when? *
Your answer
Do you want to request a specific counselor? If yes, who?
Your answer
What diagnosis qualifies your child for Camp Rainbow? *
Your answer
When was your child diagnosed? *
Your answer
Who is your child's Medical doctor? *
Your answer
Doctor's Address:
Street: *
Your answer
City: *
Your answer
State: *
Your answer
Zip: *
Your answer
Office Phone: *
Your answer
What does your child know or understand about his/her illness?
Your answer
Please list your child's information:
Weight: *
Your answer
Height: *
Your answer
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: *
Your answer
Does your child need any unusual assistance with personal care needs? *
Your answer
Has your child stayed away from home before? *
Your answer
Does your child have any problems communicating with others? *
Your answer
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) *
Your answer
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 15th at 9:00am. Who will pick up your child? *
Your answer
Any known allergies to medications (Please list). *
Your answer
Medication given to you child at home. List Medication Name, Amount Given, and How Often. *
Your answer
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 10 th to June 15th, 2019. 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: *
Your answer
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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