Adult Camp Application for Elks Camp Grassick

Adult Camper Application for Elks Camp Grassick

Application for all camp sessions for individuals ages 21+
What camp session is this individual applying to? (Note: We will try to honor session requests as much as possible, but acceptance will be determined based on space and staffing.)*

Adult Camp Session 1 (August 2 - August 6 )Adult Camp Session 2 (August 9 - August 13)
Permission

I, as parent/guardian/staff representative of this individual (or I, as my own legal guardian), request that they be considered an applicant to Elks Camp Grassick for a camp session. I give permission for Elks Camp Grassick to obtain information to help determine eligibility for a camping session. I understand that failure to provide honest and accurate information about this individual could result in non-acceptance or early dismissal from Camp Grassick. I understand that each application will be reviewed by a screening committee who will determine if this applicant is a good fit for Camp Grassick and if so, which camp session would be the best fit. I understand that they may not be accepted or may not be accepted to the session I chose above.
Signature*
If you are unable to sign in the box above , please enter your name below. This signifies that you agree to the statement.
Identifying Information
Name of Applicant*

First NameLast Name
Preferred Name or Nickname
Gender*
Birthdate*

MonthDayYear
Age as of Camp Start Date*
Applicant's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information

Primary and Secondary Contacts may be Parent(s), Guardian(s), or Facility Staff
Name of Primary Contact*
Relationship to Camper:*
Primary Contact Email*
example@example.com
Primary Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number:
Name of Secondary Contact:
Relationship to Camper:
Secondary Contact Email
example@example.com
Secondary Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:
Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number:
Emergency Contact (Must be someone other than Parent or Guardian.)*

First NameLast Name
Relationship to Applicant*
City/State where Emergency Contact Lives*
Phone Numbers:*
Please enter a valid phone number.Format: (000) 000-0000.
Please provide the Names and Phone Numbers for an Emergency Contact(s) and/or Agency and/or Case Manager not listed above:
Information from Camp
Contact: How would you as parents/guardians/staff like to receive information from camp? (acceptance or non-acceptance, pre-camp information, reports, etc.)*

I would like to receive paper copies in the mail.I would like to receive digital copies by email.I would like to receive both paper and digital copies.

Elks Camp Grassick Fee Agreement

Please do NOT send payment until this individual has been accepted. Payment will be due at check-in unless other arrangements have been made.
Camper's Name:*

First NameLast Name
Name or party responsible for payment:*

First NameLast Name
Parent/Guardian/Responsible Party: We ask that you pay what you can towards your camper’s fee. We never turn down campers due to inability to pay and we will not ask for any proof of income. Simply pay what you feel comfortable paying, and the rest will be covered by scholarships. Paying any amount towards camp fees helps us continue to provide services for all campers. Camp fees may also be paid in payments. For more information about paying for camp, please visit the FAQ section of our website.
Please check which camp this individual is applying for: (Note: Fees will change if applicant is accepted to a session that is different from the session they initially applied to.)*

Therapy Camp - $550Skills Camp - $425Recreation Camp - $175Medical Respite Camp - $250Adult Camp - $150
I hereby agree to pay $blanks* for this individual to attend Elks Camp Grassick.
blank*
Signature
If you are unable to sign in the box above , please enter your name below. This signifies that you agree to the fee agreement on this page.
If you have any questions, please feel free to call camp at 701-327-4251.
Should be Empty:

Rows	Independent	Supervision	Minimal Assist	Moderate Assistance	Total Assistance
General Toileting
Toileting after bowel movement
Showering Body
Washing Hair
Combing/Brushing Hair
Styling Hair (particularly if long)
Dressing while dry
Dressing while wet
Brushing Teeth
Mobility
Washing Hands
Swimming
Serving themselves food
Pouring beverages
Cutting food
Feeding themselves

Rows	Below Average for Age	Average for Age	Above Average for Age
Maturity
Self Esteem
Independence
Necessary Supervision
Relating to Others

Rows	Below Average for Age	Average for Age	Above Average for Age
Maturity
Self Esteem
Independence
Necessary Supervision
Relating to Others

Adult Camper Application for Elks Camp Grassick

Permission

Identifying Information

Contact Information

Information from Camp

Home Information

Activities of Daily Living:

Social Study

Behavior Study

Medical Form/Health History

Identifying Information

Epilepsy and/or Seizure History

Allergies & Dietary Restrictions

Vaccines

Assistive Devices

Medications

Health History

Elks Camp Grassick Fee Agreement