Loading weather... Camper Registration Form 1 2 3 4 Step 1: Core Contact Information Camper Details First Name * Last Name * Email * Date of Birth * Address Country Address Line 1 * Address Line 2 City * State * ZIP Code * Parent or Caregiver First Name * Last Name * Relationship to Applicant * Phone * Emergency Contact * Step 2: Medical & Diagnosis Profile What School Does Your Child Attend? Physician Name * Physician Phone Primary Diagnosis * Physical Challenges (List all impairments/mobility limitations) * Significant Past Medical History (Within last 12 months) * Step 3: Medical Needs & Personal Care Does The Applicant Have a Seizure Disorder? * -- Select Option -- Yes History of, but controlled No Hearing Impairment? * Yes No Hearing Aides or Assistance Device Used * Vision Impairment? * Yes No Incontinence Details * -- Select Option -- Potty Trained Needs minor assistance Diapering Needs Step 4: Communication, Mobility & Environment Applicant's Form of Communication (Check all that apply) * Uses Speech Uses Communication Device Uses sign or hand movement Uses Eye Movement Language Spoken at Home * Best Way to Communicate With Applicant * Mobility * -- Select Option -- Wheelchair Walker or Stander Gait Trainer Can roll when lying on floor Scoots while sitting Special Diet/Allergies & Food Restrictions * Classroom Type * -- Select Option -- General Education Classroom Self Contained Classroom Homeschooled Previous Next
