2025 TRAC Lakeland Camper Application

Teen Reach Adventure Camp (T.R.A.C) is a positive, faith-based camp experience especially designed to ensure success for at-risk youth, usually residing in foster care, who have likely experienced abuse, abandonment or neglect.

Each three-day camp focuses on safety by providing a unique ratio of one counselor to every two campers. Rather than being co-ed, each camp is single-sex to promote a greater level of comfort between staff and attendees. Volunteers are vetted and trained, including a camp nurse and behavioral specialist who are available to meet the needs of campers.

Every youth is offered complete confidentiality. No volunteers will take photos, other than the camp photographer who will take pictures for individual camper photo albums. All T.R.A.C. promotional videos/pictures will be edited for confidentiality.

Campers enjoy the outdoors, waterfront activities, make crafts and participate in a low- level challenge course designed to build self-respect, teamwork, trust and communication while having fun. Through encouragement and quality time with each teen, volunteers at T.R.A.C. strive to give campers a sense of hope that the past doesn’t have to define the future.

If you have any questions, please e-mail info@TRACLakeland.org or call (305) 978-3542.
Camper’s first name
Camper’s last name
Preferred name/nickname
Biological sex (M/F)
Gender Identity (if different from biological sex)
Age
Emotional age
Shirt size (Adult sizes: S - XXL)
Name of teen’s case worker
Case worker’s phone number
Case worker’s email address
example@example.com
Name of case worker’s supervisor
Supervisor’s phone number
Name of person teen is living with
Relationship to teen (bio-parent, adoptive parent, foster parent, group home, relative)
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Length of time teen has been in this home
Street address
City
County
Zip Code
Emergency contact name (during camp)
Emergency contact phone number (during camp)
Has teen attended Royal Family KIDS Camp or Teen Reach Adventure Camp? (Yes/No)
If yes, which one and at what location?
Names and ages of biological siblings who are applying to camp
Names and ages of other foster children living in this home who are applying to camp
CAMPER PERSONALITY. Please help us get to know this teen better so we can provide positive interactions and activities at camp. Check boxes for words which best describe the teen most of the time.

socialquietorderlyathletickindenergeticseriouscompetitiveobserveroptimistictalkativeplannerdeterminedperfectionistnegativehumorousshypeacekeeperperformerleader
CAMPER CHALLENGES. Please check boxes for any behaviors that either occur often or are significant to note for camper safety.

Aggression / AngerBedwettingBitingEating DisorderHyperactiveLyingNightmaresRuns AwaySexual Acting OutStealingWithdrawn / Sad
Please provide any necessary comments regarding behaviors selected above.
Doctor’s name
Facility name
Phone number
Medical Insurance name
Insurance number
Does teen have seasonal allergies? (Yes / No)
Does teen have ANY food or drug allergies? (Yes / No)
If yes, please describe.
Is teen allergic to bees? (Yes / No)
Does teen carry an EpiPen? (Yes / No)
Please list ANY known medical conditions (mental or physical), illnesses or surgeries treated by a doctor in the last year.
Does teen have any physical disabilities or other limitations that could interfere with camp activities? (Yes / No)
If yes, please describe.
Is teen diabetic? (Yes / No)
Does teen have asthma? (Yes / No)
Is this teen pregnant? (Yes / No)*
*If so, the teen must have a medical release signed by her doctor and her state representative.
Please list ALL medications teen is taking.

NOTE: MEDICATIONS MUST BE IN ORIGINAL PRESCRIPTION BOTTLES FROM PRESCRIBING PHYSICIAN. THIS IS NOT THE TIME TO GIVE MEDICATION VACATIONS.

	Name of Medicine	Reason	Dosage (amount)	Time Given

Permission to Administer First Aid & Over-the-Counter Medications

I hereby give the Teen Reach Adventure Camp Nurse permission to administer first aid and the following products according to manufacturer’s instructions, or as otherwise specified.

I trust the T.R.A.C. Nurse to use his/her best judgment as situations arise, and if in doubt, he/she can call for verification.
A check means: YES, I GIVE PERMISSION for that product.

SunscreenInsect repellentLip balmRash ointmentTylenolIbuprofenAntiseptic ointmentBand-AidsAnti-itch creamAlcohol wipesCough syrupCough dropsDecongestantAntihistaminePepto-BismolTumsOther
List any specific instructions for the products above (if required):
NOTE: At camp registration, medications must be in original prescription bottles from prescribing physician. This is not the time to give medication vacations.
MEDICAL RELEASE: This health history is correct so far as I know, and the above-named minor has permission to engage in all prescribed program activities. The undersigned does hereby authorize T.R.A.C., on behalf of the undersigned, to consent to an X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by, and to be rendered under the general or special supervision of any physician/surgeon, licensed under the provision of the Medical Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, at camp or elsewhere. This authorization will remain effective while the above minor is en route to and from or involved in or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Camp Director. During camp, prescription medication will be administered to youth as directed by a physician. T.R.A.C. will do everything in its power to prevent incorrect medicine from being given. However, the local T.R.A.C./Teen Reach/DBA T.R.A.C./Teen Reach Adventure Camp, is not liable for incorrect medicine provided to us by the legal guardian, incorrect dosages given, nor is it liable for wrong labeling on medicine bottles. Legal guardians are responsible for checking in the correct medication, bottles and dosages at the time of registration. This is not the time to give medication vacations to your teen.

LIABILITY RELEASE: Every precaution will be taken to protect campers and volunteers from harm, but the local T.R.A.C./Te e n Reach/DBA T.R.A.C./Teen Reach Adventure Camp is not liable for injuries/death that youth or volunteer staff may incur while camping or participating in T.R.A.C. activities. If he/she is injured, I have given medical information and permission to take him/her to a medical facility for proper care. All extension activities are included in the liability release. I release the local T.R.A.C./Teen Reach/DBA T.R.A.C./Teen Reach Adventure Camp, from any liability surrounding any injuries/death to the camper and/or the camper’s unborn child if the camper is pregnant.

As legal guardian of the above youth, I agree that all the information provided in this application is accurate. I also agree to both the medical and liability releases and the permission to administer first aid and over-the-counter medications as indicated above.
Signature of legal guardian

Clear
NOTE: I certify that I am the legal guardian of the above applicant. To be legally binding, I must sign in pen.
Printed name
Date

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Date
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