Disability EmpowHer Camp Camper Application
Applicant (Camper) Name
*
First Name
Last Name
Applicant Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Email Address
*
example@example.com
Applicant Cell Phone Number
Please enter a valid phone number.
Applicant Home Phone Number
Please enter a valid phone number.
Parent 1
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent 2 (optional)
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Email Address
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Applicant Information
*
Any other relevant demographic information?
For those who are D/deaf, hard of hearing, or with other speech/communication disabilities or differences, please indicate phone preferences (e.g. VRS/texting on cell):
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Parent/Guardian Section
The following questions are for parent(s)/guardian(s): How long and how many times has your child been away from home without her parent/guardian? (i.e. camps, sleepovers, vacations without parent/guardian, etc.)
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How does your child manage being away from home without a parent/guardian? What tips and information regarding your child's ability to manage being away from home without a parent/guardian should we be aware of, if any?
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Please list all accommodations (as applicable) that your child would need to fully participate in our program, keeping in mind that we will have limited access to modern conveniences such as indoor plumbing while camping. Please note that we DO have access to electricity specifically and only for charging wheelchairs and/or assistive technology.
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What medications does your child take? What are the medications for?
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Does your child have any regular medical routines (i.e. cathing four times per day, performing a bowel program, checking blood sugar, etc.)?
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Can your child take her medicine and/or perform her regular medical routines independently? With assistance? If assistance is needed, what type of assistance?
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What dietary restrictions does your child have, if any?
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Does your child have any allergies?
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Participants go without all electronics (with the exception of devices such as power wheelchairs, medication delivery devices, augmentative communication devices, etc.) during the camping portion of our program, except for phone time once during their stay. Do you foresee any challenges with this policy for you or your child?
*
EmpowHer Camp is a year-long program. This includes: (1) A week of camping in the Adirondacks, followed by (2) Completing an emergency preparedness project at home for one year while regularly talking with a mentor, and concluding with (3) A week-long trip to Washington, D.C.. Do you foresee any challenges in completing the program for you or your child?
*
Please rate your child’s skill level in the following areas on a scale of 1 – 10.
To guide you, 1 means “None: My child has no experience in this area,” 5 means “Good: My child has some knowledge and a little experience in this area” and 10 means “Excellent: My child is an expert and has NO room for growth in this area.” You can score any number between 1-10.
Survival Skills
Camping (sleeping bag set-up, using an outhouse)
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None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Fire Building
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Navigation (reading a map/compass, knowing one's way)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Living Without Modern Conveniences (i.e. indoor plumbing, electricity, phones)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Independent Living Skills
Physical Self-Care (dressing, bathing, toileting, transfers)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Mental/Emotional Self-Care (coping skills, emotional regulation, etc.)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Cooking
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Self-Advocacy (speaking up for yourself and your needs)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Planning
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Time Management (getting places on time, planning ahead for tasks)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Cleaning
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Leadership Skills
Public Communication/Presenting (communicating in front of others in a formal way with or without practice)
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Communication Skills (socializing, written communication, active listening, etc.)
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Problem Solving
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Adaptability (being flexible when things change)
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Teamwork
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Discipline (taking initiative, being responsible, finishing tasks, etc.)
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
How would you rate your child's confidence on a scale of 1-10?
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Please feel free to describe additional information about your child that you would like to share (related to school, family, friends, and including any recent life events):
Please click here to confirm that you have read the Camp Description and Year-Long Commitment information, as provided in the FAQ at the following link: https://www.disabilityempowhernetwork.org/camp-application
I have read and agree to the above information
Thank you for completing the first part of the application!
The next portion is for your child to complete. She is required to answer the questions on her own or, when necessary, with the assistance of a non-parent/guardian. If your child requires accommodations to complete the form, please email us at disabilityempowhernetwork@gmail.com.
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Applicant Section:
Please fill this out by yourself, or with help from someone who is not your parent or guardian. We are so excited that you’re interested in EmpowHer Camp! We want to make this the best possible experience for you and the other participants in the program. We're asking the questions below to get to know you better. We’re not checking how you spell or write. We do want you to complete the questions below without help from your parent/guardian. We really want to hear from you. There aren't any "right" or "wrong" answers; just be yourself and let us know who you are. Thank you!
What do you think makes a good leader? What are you looking to gain by participating in EmpowHer Camp? (up to 500 words)
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0/500
Do you currently have any role models that are successful women with disabilities? If yes, please tell us about them.
*
What about your school do you like? What do you find challenging?
*
How has the pandemic impacted your life?
*
How do you feel about camping away from home for one week?
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What’s the longest you’ve been away from home without your parent(s)/guardian(s)? Where did you go, what did you do, and how did it feel to be away from your parent(s)/guardian(s)?
*
Tell us about something you're proud of:
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Everyone needs help at camp. That said, disabled people often require "reasonable accommodations." A reasonable accommodation is an adjustment made in a system for an individual based on needs. For example, a blind person may require the accommodation of Braille or large print written materials. A wheelchair user may require the accommodation of a ramp or access to electricity to charge their wheelchair. Other examples can include access to an alternative/augmentative communication device, grab bars, a raised bed, and more. What accommodations, if any, do you require? Remember -- it is ALWAYS okay to ask for help! This will not determine whether you are accepted to camp.
*
Are there any other kinds of necessary help you receive during your day-to-day life that you might need at camp (i.e. brushing your hair, brushing your teeth, cutting up your food, keeping track of your schedule, etc.)?
*
Do you take any medications? Do you know what your medicine is for?
*
Do you have any regular disability related routines? (such as going to the bathroom at a certain time or eating specific things?)
*
Can you take your medicine and/or perform your regular medical routines independently? With help? If you can do it with help, what kinds of help do you need?
*
Participants go without all electronics that are not medically necessary during the camping portion of our program, except for phone time once during their stay. Do you foresee any challenges with this policy for you?
*
EmpowHer Camp is a year-long program. This includes: (1) A week of camping in the Adirondacks, followed by (2) Completing an emergency preparedness project at home for one year while regularly talking with a mentor, and concluding with (3) A week-long trip to Washington, D.C.. Do you foresee any challenges with completing the program?
*
Please rate your skill level in the following areas on a scale of 1 – 10.
To guide you, 1 means “None: I have no experience in this area,” 5 means “Good: I have some knowledge and a little experience in this area” and 10 means “Excellent: I am an expert and have NO room for growth in this area.” You can score any number between 1-10.
Survival Skills
Camping (sleeping bag set-up, using an outhouse)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Fire Building
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Navigation (reading a map/compass, knowing your way)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Living Without Modern Conveniences (i.e. indoor plumbing, electricity, phones)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Independent Living Skills
Physical Self-Care (dressing, bathing, toileting, transfers)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Mental/Emotional Self-Care (coping skills, emotional regulation, etc.)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Cooking
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Self-Advocacy (speaking up for yourself and your needs)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Planning
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Time Management (getting places on time, planning ahead for tasks)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Cleaning
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Leadership Skills
Public Communication/Presenting (communicating in front of others in a formal way with or without practice)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Communication Skills (socializing, written communication, active listening, etc.)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Problem Solving
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Adaptability (being flexible when things change)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Teamwork
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Discipline (taking initiative, being responsible, finishing tasks, etc.)
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
How would you rate your confidence on a scale of 1-10?
*
None
1
2
3
4
5
6
7
8
9
Excellent
10
1 is None, 10 is Excellent
Is there anything else you'd like us to know about you?
Please click here to confirm that you have read the Camp Description and Year-Long Commitment information, as provided in the FAQ at the following link: https://www.disabilityempowhernetwork.org/camp-application
*
I have read and agree to the above information
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COVID Considerations
EmpowHer Camp will be held at John Dillon Park in the Adirondacks, NY. This is an outdoor facility with miles of trails. All participants will sleep in lean-tos. Each lean-to will sleep three to four participants. Hand sanitizer and sanitizing wipes will be available at every lean-to, in all outhouses, and in all activity areas. Every person will be required to be vaccinated in order to attend camp, unless medically unable to be vaccinated. All persons attending camp will be required to test negative for COVID within three days of attending camp. All participants will be required to sign a liability waiver which will include recognition that the participant is freely volunteering to participate in EmpowHer Camp and that the participant recognizes the risks of COVID-19. Parents/guardians will also be required to sign this form. If it is determined that we are unable to host EmpowHer Camp due to statewide or national COVID safety concerns, we will make our best efforts to ensure that selected participants can participate in EmpowHer Camp when it is safe to do so. Please note all COVID-related rules are subject to change as per CDC guidance.
Understand and Agree
*
I have read and understand the COVID Considerations as stated above.
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