Camper Application- to be completed by Guardian
Camper Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Age as of August 1
Please Select
8
9
10
11
12
13
14
15
16
Sex:
*
Male
Female
Height
*
Weight
*
Shirt Size
*
Please Select
Child S
Child M
Child L
Child XL
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Adult XXXL
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian email
example@example.com
How would you prefer to be notified?
*
Email
US Postal mail
Guardian #1
*
First Name
Last Name
Guardian #1 relationship
*
Guardian #1 Main Phone
*
Please enter a valid phone number.
Guardian #1 Alternate Phone
Please enter a valid phone number.
Guardian #2
First Name
Last Name
Guardian #2 relationship
Guardian #2 Main Phone
Please enter a valid phone number.
Guardian #2 Alternate Phone
Please enter a valid phone number.
List all others living at this address
*
If child does NOT live with parents, please give pertinent name, address and contact information
We will NOT accept a child without an additional contact person. Please list the name and phone number of and additional person we can notify in case of emergency. MUST be a different number from those listed already.
*
First Name
Last Name
Emergency Contact Main Phone
*
Please enter a valid phone number.
Emergency Contact Alternate Phone
Please enter a valid phone number.
Back
Next
Child's Doctor
*
Hospital
Doctor's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor's Phone
*
Please enter a valid phone number.
What is your child's Medical Insurance?
*
Policy Number
*
Did your child attend Camp Onseyawa last summer?
*
Yes
No
If no, did your child ever attend Camp Onseyawa?
Yes
No
What was the most recent year?
Will your child attend any other camp this year? If yes, which camp?
*
What school/agency does your child attend?
*
Grade
*
Child's caseworker/social worker (if applicable)
Caseworker phone number
Please enter a valid phone number.
What is your child's disability?
*
Please write a brief description of your child's disability, including any behavioral problems and any special needs he/she may have, which will help in te staff's understanding of your child
*
Back
Next
Does your child have seizures?
*
Yes
No
Date of most recent seizure?
Describe a typical seizure
On average, how many seizures does your child have in a year?
Should your child have any restrictions at camp?
*
Yes
No
If yes, what restrictions do your recommend?
Are special rest periods, other than one in the afternoon, needed?
*
Yes
No
If yes, what rest periods do your recommend?
Does your child require a wheelchair and/or other special equipment?
*
Yes
No
If yes, what equipment is required? Is there special care for this equipment required? (We recommend that, unless absolutely necessary to the child's welfare, "fancier"/more expensive equipment be substituted with rugged or expendable equipment during the 2 weeks)
Does your child have bedtime concerns?
*
Yes
No
If yes, what are the bedtime concerns?
Does your child have any allergies?
*
Yes
No
If yes, what are the allergies?
Does your child have special dietary needs?
*
Yes
No
If yes, please specify the dietary need. Please ensure the doctor has noted dietary restrictions or provided a separate medical note.
Celiac Disease
Dairy Free
Soy Free
Wheat Free
Dye Free
Other
Any other comments or information you would like the selection committee and staff to have about your child?
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform