Hope's Haven Camper Registration
2025
Demographics
Camper Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Has your camper previously attended summer camp?
*
Please Select
yes
no
If yes, was this an overnight camp?
Please Select
yes
no
Camper's Developmental Age (This may be different than their physical age and helps us group campers with their peers:)
*
Gender
*
Parent/Guardian Name
*
First Name
Last Name
Additional Parent/Guardian Name
First Name
Last Name
Email
*
example@example.com
Secondary Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Primary Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who lives in your campers household (please include name, age, and relationship to your camper)
*
Please include primary and secondary household members (if applicable)
T-Shirt Size
*
Would your camper like to be paired with a particular volunteer?
*
Please Select
Yes
No
If yes, who?
What is your camper's favorite song? We want to use this to welcome them to Hope's Haven upon their arrival!
*
We will pick a song for your child's arrival is none is provided here
How did you hear about Hope's Haven?
*
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Camper Information
What are your camper's diagnoses?
*
Is your camper currently enrolled in school or other consistent programs?
*
Please Select
yes
no
Please provide the name(s) of the current or most recent school/program your camper attended
*
What type of classroom is your camper in?
*
Examples: full inclusion, partial inclusion, home schooled, etc.
Please list any therapies, programs, or additional services your camper participates in
*
Examples: ABA therapy, occupational therapy, vocational rehabilitation, etc.
What hobbies/interests does your camper enjoy?
*
Sports, hobbies, shows, special interests, etc.
Please describe any routine your camper strictly adheres by. If none, put N/A
*
Please describe your camper's typical daily energy level
*
Please Select
Mostly stationary
Moves when prompted
Typical energy level
Active throughout the day
Constantly moving and prefers not to be still
What is your camper's sleep schedule, including any naps taken during the day?
*
Activities of Daily Living
Please be honest and transparent when completing information about your camper's activities of daily living. None of the following areas will exclude your child from admission to camp. We appreciate detailed information about your camper so we are best prepared to care for them.
Restroom - please check all that describe your camper:
*
Independent when using the restroom
Needs verbal prompting to use the restroom
Wears a brief during the day
Will communicate when they need to use the restroom
Needs minimal assistance cleaning after using the restroom
Needs full assistance cleaning after using the restroom
Can sit on the toilet unassisted
Does not use the toilet and requires full care with brief changes
Other
If you checked other, please explain:
Dressing - please check all that describe your camper:
*
Dresses self independently
Needs verbal prompting to dress themselves
Needs minimal assistance dressing themselves
Needs full assistance dressing themselves
Other
If you checked other, please describe. If your camper needs assistance with any areas of dressing please note them here:
Include if your child needs help tying shoes, putting on AFO devices or braces, buttoning clothing, etc.
Grooming - please check all that describe your camper:
*
Brushes teeth independently
Needs verbal prompting to brush their teeth
Needs minimal assistance brushing their teeth
Needs full assistance brushing their teeth
Brushes/Styles hair independently
Needs verbal prompting to brush/style their hair
Needs full assistance to brush/style their hair
Washes hands independently
Needs verbal prompting to wash their hands
Needs minimal assistance to wash their hands
Needs full assistance to wash their hands
Other
If you checked other, please explain:
Showering - please check all that describe your camper:
*
Showers independently
Needs verbal prompting to complete shower routine
Needs minimal assistance to complete shower routine
Needs full assistance complete shower routine
Other
If you checked other, please explain:
Mobility - please check all that describe your camper:
*
Moves around independently
Needs some assistance with mobility
Needs full assistance with mobility
Other
Please describe what equipment or devices your camper uses and how they are utilized
Include the use of any special equipment or devices (i.e. wheelchair, walker, gait trainer, AFO braces, etc.)
Eating - please check all that describe your camper:
*
Serves food, eats, and cleans up after mealtime independently
Needs verbal prompting to serve food, eat, and clean up after mealtime
Needs some assistance with serving food, eating, and cleaning up after mealtime
Needs full assistance with serving food, eating, and cleaning up after mealtime
Other
If you checked other, please explain:
Please note if your child uses food supplements, has a feeding tube or other nutrition device, or any other mealtime assistance needed. (Food allergies are noted elsewhere)
Can your camper swim?
*
Please Select
Yes - independently
Yes - with a flotation device
No
At Hope's Haven we require all campers wear life jackets regardless of swimming ability (we provide this but you are welcome to bring your own)
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Medical Information
Height
*
Weight
*
Current Physician Name
*
Current Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Physician Phone Number
Please enter a valid phone number.
Health Insurance
This information is required in case of a medical emergency
Primary Insurance Provider
*
Primary Insurance ID #
*
Primary Insurance Policy Holder's Name
*
Primary Insurance Policy Holder's Date of Birth
*
Secondary Insurance Provider
Secondary Insurance ID #
Secondary Insurance Policy Holder's Name
Secondary Insurance Policy Holder's Date of Birth
Has your camper had a seizure within the last 6 months?
*
Please Select
Yes
No
If yes, what did this look like?
Please note that if your child has had a seizure within the last 6 months that they we will require medical clearance from a physician before camp. This form will be provided to you via email after your child's application is approved.
Please provide any additional information about your camper's health including use of a catheter, heart monitor, CPAP machine, or any other medical device.
Does your child have bowel issues?
*
Please Select
Yes
No
If yes, please explain and provide information on what help alleviate the issue
Allergies
Does your camper have a bee or a wasp sting allergy?
*
Please Select
Yes
No
Does your camper have any drug allergies?
*
Please Select
Yes
No
If yes, please list drug allergies
If yes, please list other allergies
Does your camper have any food allergies?
*
Please Select
Yes
No
Please list your camper's food allergies.
Does your camper have any other allergies?
*
Please Select
Yes
No
If yes, please explain
Dietary Needs
Is your camper on a specific diet?
*
Please provide details about your camper's dietary needs.
Please provide any other information about your camper's dietary needs or meal time routines, including use of assistive feeding devices. If your camper eats a limited variety of foods (ie: only eats chicken nuggets,) you may be asked to provide food to be prepared for your camper. Please note here if you would like to discuss your camper's food needs further and a member of leadership will reach out to you.
If your camper mensurates, please describe what hygiene products they use and their level of independence with these products:
Do you have any additional information you would like to share with our nurses?
Medication
Please be as detailed here as possible. You will receive an email confirming medication has not changed prior to your arrival at camp. Upon arrival at camp, nurses will review this with you a final time to ensure accurate dispensing of medication.
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Behavioral Health
Please be as transparent as possible in the following section. The majority of campers will be eligible to attend camp, regardless of their history of emotional/behavioral disturbances. At Hope's Haven we are prepared to deal with a variety of behavioral needs that frequently accompany this population of children. However, some may not be appropriate for camp if they pose a significant risk of safety for other campers, volunteers, or staff. Leadership may request an informational meeting before approval of application depending on your answers. For more detailed information, see our website's informational section on behavioral policies for camp.
Self Injurious Behaviors - please answer for behaviors displayed within the past 6 months (check all that apply)
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Camper engages in self injurious behaviors frequently (3+ incidents per week on average)
Camper engages in self injurious behaviors occasionally (less than 1-3 incidents per week)
Camper engages in self injurious behaviors rarely (1-3 incidents per month)
Camper has a history of self injurious behavior, but has not engaged in self injurious behaviors in over six months
Camper has never engaged in self injurious behavior
Please detail your camper's self injurious behaviors (how camper engages in this behavior, triggers for this behavior, and what helps calm camper/keep them safe):
Aggression Towards Property (check all that apply):
*
Camper has never acted aggressive towards property
Camper has a history of acting aggressive towards property, but has not had an incident in over 6 months
Camper has acted aggressive towards property within the past 6 months
Camper rarely acts aggressive towards property
Camper sometimes acts aggressive towards property
Camper frequently acts aggressive towards property
Please detail what your camper's history/current behaviors are with acting aggressively towards property (including environments behavior is present in, triggers, preventative measures you take, and coping strategies that help post-incident):
Aggression/Violence Towards Others - NOT including siblings (please check all that apply):
*
Camper has never acted aggressive/violent towards others
Camper has a history of acting aggressively/violent towards others, but has not had an incident in over 6 months
Camper has acted aggressive/violent towards others within the past 6 months
Camper acts aggressive/violent towards others rarely (less than 3 incidents in the past 6 months)
Camper acts aggressive/violent towards others occasionally (3-6 incidents in the past 6 months)
Camper acts aggressive/violent towards others frequently (6+ incidents in the past 6 months)
Please detail what your camper's history/current behaviors are with acting aggressively towards others (including environments behavior is present in, triggers, preventative measures you take, and coping strategies that help post-incident):
Language (use of curse words or discussion of inappropriate topics):
*
Camper does not curse or use inappropriate language
Camper curses or uses inappropriate language rarely
Camper curses or uses inappropriate language occasionally
Camper curses or uses inappropriate language frequently
It is typical for all children to become dysregulated at times. What coping strategies do you or your camper implement to regulate their emotions?
*
Examples: take a break, listen to music, deep breathing, comfort object, etc.
Does your camper struggle to transition between activities?
*
Please Select
Yes
No
If yes, please describe what strategies are helpful at home or school to help your camper with transitions (visual schedules, reminders, timers, etc.)
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Communication
Please check all that apply:
*
Will interact with peers
Will interact with caregivers
Can identify emotions
Can communicate emotions
Often becomes overwhelmed in social settings
Requires some space to regulate emotions
Will initiate social interactions
Needs to be encouraged to participate in social settings
Will participate in most social activities
Other
Please share any additional information about your camper's social interactions and needs
Does your camper communicate verbally?
*
Please Select
Yes
No
Somewhat
Does your camper use an assistive communication device?
*
Please Select
Yes
No
Does your camper primarily use American Sign Language to communicate?
*
Please Select
Yes
No
What is the primary language spoken at your camper's home?
*
Please provide any additional information relevant to your camper's communication needs, including the best way to communicate with your camper.
Sensory Needs
Does your camper have sensory issues?
*
Please Select
Yes
No
If you indicated your camper has sensory issues, please describe them and what helps your camper cope including self soothing objects, headphones, etc., and how often they use them.
Does your camper elope (run away)?
*
Please Select
No history of eloping
Yes - history of eloping but no incidents within 6 months
Yes - rarely, but within the past 6 months
Yes - occasionally
Yes - frequently
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Finalization
Signing below indicates that all of the above information is reported accurately and completed to the best of your knowledge.
Please use this space to share any additional information you would like us to know about your camper's personality, needs, etc. Our staff carefully reviews this information prior to your camper's arrival and uses this information to care for your camper. We look forward to learning more about your camper!
Legal Guardian Signature
PAYMENTS - payment for camp will be sent via a QuickBooks invoice to the email you provide below. Payments can be made in installments but must be completed prior to camp in order for your camper to attend.
*
Provide the email you would like your invoice to be sent to
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