2012 Christmas Family Camp CAMPER Form

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This is an overnight camp request form to participate in an invitational Christmas Camp Session December 7-9th, 2012. This is the final mock camp session for Camp Craig Allen this year.
(FYI- "Mock" session just means that we ARE having full camp weekends, full of fun and modified activities, but this is NOT the all-barrier-free facility in which we built from the ground up).

All Campers must complete the form in its entirety.
Please understand our Camp Craig Allen mission and know our current camp programs are designed specifically for physical disabilities for adults 18 years and older at this time.
However, the Christmas Family Camp is for all ages. Your immediate family will have a cabin of your own.

This “CHRISTMAS FAMILY CAMP” is desingated for you as the disabled camper and your family. Reservations for cabins must be made by Dec 1st using this form for the disabled camper.

All answers are for Camp Craig Allen use only and will help us determine cabin assignments, volunteers needs, and over all logistics of a safe and fun session. Information will be confidential and only used for Camp Craig Allen purposes.

All Campers, regardless of their physical capacity, must bring a "friend" as this is a camp policy. All campers which are not complete self-care must have a care taker to help with all personal needs.

Thank you and we will see you at Camp!

Your Name *

First and last name and "nickname" (if any)

Your email address *

Your contact phone number *

Second phone number

if applicable

Your Email Address *

Returning Camper? *

If you have attended a Camp Craig Allen camp session, please list the camp session(s) you attended

Gender *

Male

Female

Required

Your current age *

List any participation in other programs for the disabled *

What is your relationship status? *

What is your specific physical disease(s) or injury(s) (if SCI-provide level) *

Provide details that will help us know your level and include all if you have mulitiple.

Describe your basic physical abilities *

This means:can you feed, transfer, dress, push own chair? Decribe what you can do so we understand your capabilities

List any and all Respiratory issues

Specifics on your breathing, include machines if applicable

List any and all Cardiac issues

Specifics on any heart problems; include if you have a pace maker/defib

When was diagnosis, on set or injury of your physical disability? *

This helps us know your length of time you have been disabled

Have you had any recent surgery?

Recent is under 12 months; Explain in detail what and why if applicable

Do you have any upcoming, possible, or potential surgery scheduled, planned or anticipated?

List details if applicable and put when (even if estimating when it would be in the future)

Where did you hear about Camp Craig Allen? *

Tell us when and where you heard of us

Have you ever been to a over night camp session? *

Any type of "Camp", even as a child

yes

This is an overnight camp with a full weekend session, are you available to stay the entire session? *

Check-In is Friday 3pm and Check-Out is Sunday at noon

yes

What is your transportation arrangments to and from the Camp Session? *

We do not provide any transportation, therefore you will need it confirmed prior to arrival

Who is your attending Guest? (include relationship,age,gender and role) *

Each camper is required to bring one guest as their helper. Unless you are completely self sufficient in ALL of your personal care (bathing,tolieting/self cath), then you are not required to bring a guest

What Mobility devices do you use on a regular basis? *

Power w/c, scooter, manual w/c, walker, cane, etc.

List ALL medical devices/equipment you use on a regular basis *

Include your service dog if applicable

Can you do your own transfers? *

If you are self sufficient in your self care, but do sometimes need assistance in transfers, please explain

Do you have ANY special requirements of food? *

This also includes food alergies, please explain or put none

List ALL medications,dosage, and what you take them for. *

Note: you will be required to bring, store and administer your own medications.

Do you have ANY medical issues other than your actual disability? *

Pressure sores, rashes, allergies, cuts, bruises, blot clots, sprains, broken bones, headaches-list them all in detail, or none

When is the last time you had a physical or checked by a health care professional? *

Include any relavant information of why you went to the Dr.

List ANY mental, behavior, ADD, ADHD, or cognitive issues you have, if any *

Explain in detail

In your Camp session, you will be fishing, swiming, interacting in games and sports in an adaptive activity, will you participate in every opportunity available? *

yes

Option 3

Why do you want to come to camp and what do you hope to get out of the weekend session? *

Share your thoughts...

What is your job status? *

List your company, your job, hours or if you are looking for work, or what your occupation is

List any other information that we should know about you *

any special requirments or request...

For Family Camp (Dec 7-9, 2012only): Will your family be joining you?

Family= Spouse, children, siblings. Include number of relatives attending, their age, & the relation to camper

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