2013 CAMP WEEKANEATIT CAMPER APPLICATION
Please complete this camper application and submit with fee to reserve a spot at Camp Weekaneatit 2013:  June 23-28  for 8-17 year olds with Celiac Disease or Gluten Intolerance and their siblings.  This camp will be held at the Camp Twin Lakes, Camp Dream facility in Warm Springs, Georgia.

Once we have received this application online AND  the registration fee--which you can submit through Pay Pal on our www.glutenfreecamp.org  site or through the mail, we will review the application and you will be notified when you have been accepted to this years’ camp program.  You must have your registration fee in before your spot is reserved.  

Applications will be accepted on a first come, first served basis.  There is a limited number of campers so reserve your spot early!   Applications are due BEFORE April 15, 2013.  Please note the fee structure which gives discounts for additional campers in the same family:
 
We do have an EARLY BIRD SPECIAL!!  If you complete the application AND submit your fee BY FEBRUARY 15, 2013 the fee structure is:
First Camper:  $550
Each Additional Camper from the same family:  $500


SUBMIT PAYMENT ANYTIME AFTER FEB. 15, 2013:
First Camper:  $600  


Each Additional Camper from the same family:  $550

Please submit payment through the PayPal button on the www.glutenfreecamp.org site (make certain to include your camper name in the payment form)
OR
Please make check payable to The Georgia Celiac Foundation/ with Camp Weekaneatit AND your camper name(s) in the memo line.  Mail your camp fee to:

Mary Bohdan  
100 Tall Timber Court
Fayetteville, GA 30215

After we are in receipt of this application AND your fee  (online verification of payment or cleared check), we will review your application and notify you of your acceptance.  You will then be asked and directed to complete additional forms and supply additional information.

For any questions, please call or email Mary Bohdan at:

770-716-7682
campweekaneatit@gmail.com 


AT THE END, MAKE SURE TO PRESS SUBMIT.  IF YOU DO NOT GET A THANK YOU, YOUR FORM HAS NOT BEEN SUBMITTED.  LOOK DOWN THE FORM AGAIN AND ANSWER ANY QUESTIONS HIGHLIGHTED IN RED THAT WERE REQUIRED QUESTIONS.    PRESS SUBMIT AGAIN!
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Camper's  Name *
Preferred Name for Name Tag
Date of Birth *
Age *
Please indicate age camper will be at camp.
Grade *
Please indicate current grade in school.
Sex *
Social Security Number *
Parent/Guardian Name *
Relationship to Camper
Street Address
City
State
Zip Code
Primary Phone *
Secondary Phone
Other Phone
Email Address *
Note:  All correspondence will be communicated via email, so please check your email for updates!
Secondary Email Address
Please complete only if you want correspondence sent to this account.
Emergency Contact Name *
Person to be contacted in case of emergency if parent/guardian cannot be reached.
Relationship to Camper
Emergency Contact Primary Phone *
Emergency Contact Secondary Phone
Emergency Contact Other Phone
Insurance Company Name *
Phone *
Address
City
State
Zip Code
Policy Number
Are you a Celiac/Gluten Intolerant camper or the sibling? *
If you are a sibling, indicate the Celiac's name.
Date of Diagnosis of Celiac Disease *
If you are a sibling, indicate "sibling."
Diagnosing Physician's Name *
If you are a sibling, indicate "sibling."
Briefly Describe Reaction to Gluten *
If you are a sibling, indicate "sibling."
Dietary Restrictions *
If other, please describe. *
Note:  We will do our best to accommodate additional dietary restrictions other than GF.   However, please only list those that are necessary for your child and that are followed on a normal basis at home.
Medication Allergies *
List all known.  Describe reaction and management of the reaction.
Food Allergies *
List all known.  Describe reaction and management of the reaction.  
Other Allergies. *
List all known.  Include insect stings, hay fever, asthma, etc.  Describe reaction and management of the reaction.
Has your child/Does your child.... *
If yes, check the box.
Required
If you answered yes to any of the above, please explain.
Which of the following has your child had? *
Please note:  If you child has been exposed to any communicable disease, particularly chicken pox, measles, or mumps, 1 to 3 weeks prior to camp, please contact us as soon as possible.  
Required
Are your child's vaccinations up to date? *
Required
If no, please explain.
Medication
The medical staff will store and administer any medications needed during the camp week.  PLEASE SEND ALL MEDICATIONS TO CAMP WITH YOUR CHILD IN THEIR ORIGINAL CONTAINER WITH WRITTEN INSTRUCTIONS.  It is expected that each family will supply in advance any routine medications needed.  Specific instructions on how to send medications and the medication check-in process will be sent to you closer to camp.
Check one of the following boxes. *
List each medication name, dosage, and frequency.
Name of Pediatrician *
Pediatrician's Phone Number *
Name of GI *
GI's Phone Number *
Does your child use any special equipment such as a walker, crutches, wheelchair, or prosthesis?  Please explain.
Please list any physical restrictions or activity limitations (i.e. no swimming, no prolonged sun exposure, no competitive sports, sight or hearing loss, etc.).
Is there anything we should know about your child that will make his/her adjustment smoother?
Is your child able to function at his or her age level?  Please describe.
Describe any bedtime or sleep habits (eg. sleeps with parent, toys, talks/walks/ in sleep, etc.).
Does your child have any serious fears?  Please describe.
Please indicate any further information about your child's medical and/or emotional needs that you feel we should know. Please include if your child sees a psychiatrist or psychologist regularly.
Camper's T-shirt Size
If your child would like to share a bunk room with a friend or sibling, please list by name.
REQUESTS WILL ONLY BE CONSIDERED FOR CAMPERS IN THE SAME AGE RANGE and will be assigned at camper check-in.  NOT GUARANTEED!
Where did you hear about our camp?
If you would like to be considered for a limited number of scholarships, please provide an explanation of need.
BE SURE TO CLICK SUBMIT!!!!!
MAKE SURE TO PRESS SUBMIT. THEN,  IF YOU DO NOT GET A THANK YOU, YOUR FORM HAS NOT BEEN SUBMITTED.   LOOK DOWN THE FORM AGAIN AND ANSWER ANY QUESTIONS HIGHLIGHTED IN RED THAT WERE REQUIRED QUESTIONS.  
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