Camp 54 Application 2022

Applicant Information

Does the applicant have the Indiana Medicaid Waiver? The waiver is required to attend services at Grant's House. If no, please reach out to youthservices@wabashcenter.com to learn more or for help with the waiver application*

YesNo

Name of Applicant*

First Name Last Name

Address*

Street Address

Street Address Line 2

City State

Zip Code

Date of Birth*

Date

Grade (entering)*

Applicant's Shirt Size

Parent or Guardian's Name*

Phone Number*

Area Code Phone Number

Email*

example@example.com

EMERGENCY CONTACT during camp session

Same as person above

Name*

First Name Last Name

Phone Number*

Area Code Phone Number

Relationship to Camper*

Name of Individual(s) That Camper May Be Released To*

Waiver Case Manager Name*

First Name Last Name

Case Manager Email*

example@example.com