Camp Benedict 2024

Camp Benedict 2024

June 3rd - 6th, 2024
Who is completing this form?*
Single ApplicantGroup Application
Primary Applicant
We value inclusivity and strive to create a welcoming and safe environment for everyone. Please share your legal name with us. If you have a chosen name that you prefer to be addressed by, please feel free to provide it in the next line. We respect and acknowledge that everyone has the right to self-identify and we will ensure that we use your preferred name throughout the camp.*

First NameLast Name
Chosen Name, if different than your legal name. Skip this if it doesn't apply.

First NameLast Name
Primary applicants Phone Number*
Please enter a valid phone number.
Is this a mobile (textable number) or a landline?*
Primary applicants Email*
NOTE: a valid email is required for all communications
Primary applicants Gender (at birth or how you identify)*
We want to ensure that everyone feels comfortable and safe using our facilities. That's why we offer gender-neutral bathrooms as an option for those who prefer them. We encourage you to let us know of any specific needs you may have in the space provided at the end of the application. It's important to us that we create an environment that is inclusive and welcoming to all, regardless of gender identity or expression. The earlier you let us know your needs, the better we can plan and adapt to ensure that everyone feels valued and respected. Thank you for your cooperation in helping us create an inclusive space for everyone.
Sexual Orientation*
It is recommended that you have an active email address to apply for Camp Benedict. Alternatively, if you don't have an email address, you can ask your case manager or case worker to fill out the application for you and provide their email address. This will enable us to communicate with them regarding your application status and any other related matters. Please note that email is our primary method of communication and we will only send communication via email to the primary applicant and case managers/social workers associated with the application.
Primary Applicants Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence:*
Referral information: *
Group Members (If group application)

Skip this section if this is not a group application.
2nd Person in Group

First NameLast Name
2nd Person's Relationship to Primary Applicant
2nd Person's Date of Birth:

MonthDayYear
Date
2nd Person's Gender:
2nd Person's Phone Number:
Please enter a valid phone number.
3rd Person in Group

First NameLast Name
3rd Person's Relationship to Primary Applicant
3rd Person's Date of Birth:

MonthDayYear
Date
3rd Person in Group's Gender:
3rd Person in Group's Phone Number:
Please enter a valid phone number.
NOTE: If there are more than 3 additional people in a group application, complete this group application and start a second group application and notate it's a continuation at the end of the application.

Case Worker/Social Worker Information of Primary Applicant:
Case Worker / Social Worker Name: (If you don't have a case manager or case worker, type N/A in both fields)*

First NameLast Name
Case Worker / Social Worker Phone Number x (If you don't have a case manager or case worker, type N/A)*
Please enter a valid phone number.
Case Worker / Social Worker Email (If you don't have a case manager or case worker, type N/A)*
example@example.com
Agency/Organization of person completing this form (if not primary applicant). (Type N/A, if it doesn't apply)*

Primary Care Provider Licensed Medical Provider for Primary Applicant:
Provider's Name*

First NameLast Name
Name of Clinic:*
Providers Phone Number*
Please enter a valid phone number.
Provider's Email
example@example.com

Brief Medical Screen for Primary Applicant:
HIV Positive or AIDS diagnosis?*
Date of Diagnosis (If unsure, use best educated guess)*
Do you have any specific dietary needs? (If no, type no)*
Any additional information we may need to know? (If no, type no)*
Social Questions
YesNoUnknown (if social worker completing form)
If yes to above question, what was the relationship to applicant? (If No or unknown above, type N/A).*
Previous Attendance:
YesNo
YesNo
If yes, what year's? (best guess if unknown) (If no, type N/A).*
Transportation

Camp Benedict provides a bus from both Rainbow Health in MPLS and RAAN in St. Cloud to Camp Knutson (our Host Camp) for those wishing to utilize this option at no cost. Parking vehicles at Rainbow Health while utilizing this bus services requires registering your vehicle with us in advance so we may register it with Rainbow Health. If you plan on utilizing the bus service please let us know here. The dates, pick up times and drop off times will be posted at a later date at www.campbenedict.org once they become available.
If not utilizing our bus service....
I/We plan on utilizing the bus service. The bus service is contracted through Reichert Bus Service and is scheduled to pick up at Rainbow Health, 2577 W Territorial Rd, St Paul, MN 55114. 612.341.2060 on Monday, June 3rd, 2024, at 9:00 AM and departs sharply at 9:30 AM. The bus is scheduled to make a second pickup en route at Rural Action AIDS Network 300 E Germain St, Suite: 220 in St. Cloud at 10:48 AM and depart at 11:00 AM. NOTE: If you need help getting to the bus and live in the twin cities area, defer to your case manager or contact the transportation department at Rainbow Health in advance for assistance. *
If you need help with transportation to and from the drop-off point from home, contact the transportation dept at Rainbow Health at 612.373.2430. You must have a current transportation application and eligibility documents on file. You can get an application from your case manager or call the Transportation Program at 612-373-2430 to request an application and schedule the ride. All documents must be in by May 31st, and taxi ride requests must be called into the transportation department by Wednesday, May 31st, 2024.

Returning home, the bus departs Campgrounds at 11:15 AM on the day of departure, Thursday, June 7th, 2024, and will drop off at both locations. Drop off at RAAN is scheduled for 1:19 PM and drop off at Rainbow Health is scheduled for 2:52 PM.
Optional Vehicle Registration at Rainbow Health

Vehicle Registration at Rainbow Health: (please complete this section if you will leave your car in the Rainbow Health parking lot for the week). I/we hereby release Rainbow Health and Camp Benedict, its staff, employees, members, and agents of any responsibility or liability for loss and/or damages to my vehicle, including but not limited to theft, collision, fire, acts of God, weather, construction, etc. during overnight parking of the car in the Rainbow Health parking lot. I/we indemnify Rainbow Health and Camp Benedict, its employees, members, and agents against loss, cost, or damage incurred because of any liability whatsoever concerning my driving and/or parking my/our automobile in the parking lot. I confirm that I have liability insurance on my vehicle that is current and in effect.
Agreed to on this date: Date:Date . Legal Name of the owner of the vehicle being registered: Type a label Signature:Signature
Social Workers/Case Managers: If filling out the transportation form for clients and they are unable to sign at time of completing this online app, then use the manual transportation form located on the www.campbenedict.org website to obtain that info and their signature later and skip this section.
Vehicle Registration
Emergency Contact Information for Primary Applicant:
Emergency Contact Name*

First NameLast Name
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Email*
example@example.com
Emergency Contact Phone*
Please enter a valid phone number.
Acknowledgement Page:
To attend the camp, every applicant must submit a separate medical form (separate from this online application) that is completed by their healthcare provider or a qualifying practitioner. You have two options for submitting the medical form: you can either wait for the processing of this application to be completed and then submit the medical form or you can submit it in advance. After submitting your application, we will inform you whether you have been accepted or not. If you submit the medical form prior to being notified if you have been accepted to camp or not, and you are not accepted to camp, the medical form will be destroyed on our end. You can find this form on our website at www.campbenedict.org. If your application is approved, you will receive an email requesting this medical form if your provider or case manager/social worker has not already submitted it. You cannot attend Camp even if accepted if the medical form is not completely filled out with your provider's signature. This must be done prior to Camp.

If any of the applicants have particular medical concerns or dietary requirements, please inform us before being accepted. In this case, please provide any necessary additional information in the space provided on this online application.

Please note that our staff is not authorized to take campers offsite for appointments or medication pick-up. Therefore, all campers are required to bring all necessary medications and be physically able to attend and participate in all camp sessions. Participation in all group sessions is mandatory for all campers. All campers are required to attend all group sessions during their time at Camp Benedict. Please do not schedule any appointments outside of Camp Benedict's programming hours through Zoom. We expect all campers to fully participate in all scheduled programming without any distractions. However, there will be some downtime during the week. In case you need to schedule a medically necessary Zoom session that cannot wait, please reach out to your case manager in advance. They will help you communicate with one of our team members to discuss your scheduling needs before agreeing to the terms of the camp.
I acknowledge I have read the statement above. If I am a case manager/Social Worker or a representative of the primary applicant, I attest I have read the above statement to the primary applicant.
Name of Person who completed this form:*

First NameLast Name
Email of person who completed this form:*
example@example.com
Phone # of person who completed this form:*
Please enter a valid phone number.
Social Workers/Case Managers: If you have any additional or supplemental documentation you would like to submit with this application you may attach it below.
File Upload

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Camp Benedict 2024

Primary Applicant

Group Members (If group application)

NOTE: If there are more than 3 additional people in a group application, complete this group application and start a second group application and notate it's a continuation at the end of the application.

Case Worker/Social Worker Information of Primary Applicant:

Primary Care Provider Licensed Medical Provider for Primary Applicant:

Brief Medical Screen for Primary Applicant:

Social Questions

Previous Attendance:

Transportation

Optional Vehicle Registration at Rainbow Health

Emergency Contact Information for Primary Applicant:

Acknowledgement Page:

Social Workers/Case Managers: If you have any additional or supplemental documentation you would like to submit with this application you may attach it below.