Adult Camp Application for Elks Camp Grassick
Note:
All applicants will be screened, and applicants will be notified if they are accepted or not accepted for this year's session (even if he or she has attended before). The number of individuals accepted to Adult Camp is dependent upon staffing and our ability to care for the campers. Space for campers who require high levels of support is usually very limited. We are not able to accept adult campers who have high behavioral needs Please DO NOT send payment to camp until you have received notification of acceptance.
Identifying Information
Name
*
First Name
Last Name
Gender
*
Male
Female
Nickname or Preferred Name
Birthdate
*
-
Month
-
Day
Year
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Age as of Camp Start Date
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Numbers
*
Please indicate whose number(s) you are providing.
Camper Email or Parent or Guardian Email
*
example@example.com
Name of Parent(s) or Guardian(s), if applicable
Emergency Contact
*
First Name
Last Name
Relationship to Applicant
*
City/State where Emergency Contact Lives
*
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Name of Agency or Case Manager, if applicable
Address of Agency or Case Manager, if applicable
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number(s) for Agency Contact or Case Manager
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General Information
Diagnosis
*
Applicant lives:
*
Independently
Independently with Staff/Assistance
with Family
Group Home
Nursing Home
Other
Activities of Daily Living:
Please give an evaluation of the applicant's ability in the area of daily living skills. How independent is he/she?
*
Level of Supervision Needed for Each:
*
Independent
Supervision
Minimal Assist
Total Assist
Dressing
Eating
Mobility
Toileting
Bathing
Does this individual have any issues with bowel or bladder control?
*
yes
no
Does he/she wear an incontinence product at any time?
*
yes
no
Does this individual have any special dietary needs?
*
yes
no
If you answered yes to any of the previous 3 questions, please explain.
Describe this person's swimming abilities:
*
non-swimmer
beginner
intermediate
advanced
Does he/she need to wear
*
lifejacket (Note: All individuals will wear lifejackets on boats and in deep water.)
earplugs
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Social Study
Personal Traits: Please describe this person's maturity level, self-esteem, and level of independence in the home environment.
*
Social Adjustment: How does this person relate to others in the home and community?
*
Does this person have any repetitive behaviors, stims, or tics?
*
Yes
No
Please describe the repetitive behaviors, stims, and/or tics?
Does this person have any behaviors, periods of dysregulation, or physical outbursts?
*
Yes
No
What sets off this behavior? Is there anything that escalates the behavior?
What does the behavior look like?
How long does a behavior typically last?
How often does he/she exhibit these behaviors?
Is there anything that deescalates the behavior? What calms him or her down?
Are there any behavior plans or therapeutic practices that work with this individual that we should continue at camp? If a behavior plan is in place, please attach.
Upload Behavior Plan Here.
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Please list a few hobbies or interests of this individual.
*
Is this person afraid of anything? Does he/she have nightmares? Please describe. Is there anything that comforts him or her?
*
Has this person ever attended a summer camp before?
*
Yes, has attended Camp Grassick.
Yes, has attended another overnight camp.
No, they have never attended a summer camp.
If no, how do you feel that this person would adjust to being away from home and in a camp environment? How do you feel this person will adjust to living with 5-8 cabinmates?
At camp, there is a full schedule of activities and lots of sensory input (activity, noise, changing weather, etc.). Do you feel that this person will be able to self-regulate with all the external stimuli and keep pace with a more active schedule?
Is there any other additional, pertinent information about this individual that you feel would be helpful to Camp Grassick?
Upload any other pertinent information here.
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