2025 Camp Brainstorm Application

APPLICATION DEADLINE MAY 1, 2025

BRIEF OVERVIEW

Camp Brainstorm Mission: To provide a safe, enjoyable, residential camping experience for children with a primary diagnosis of epilepsy, to build self-esteem by promoting self-confidence, competency, and social interaction, and to foster independence in a safe environment away from home.

Camp Brainstorm is a 5 day/4 night residential summer camp for children with epilepsy ages 8 to 17 held at Camp Aranzazu in Rockport, Texas. This year, Camp Brainstorm is June 16-June 20, 2025.  Often, children with epilepsy are denied the privilege of attending summer camp because of their epilepsy, but that is not the case at Camp Brainstorm. Camp is a place where children can try new things in an environment that is safe, encouraging, and supportive.

The support can be found through talented individuals who volunteer their time and efforts to ensure your camper has the best week of the year. Our staff is fully trained in seizure first aid and camp safety. With a camper-to-staff ratio of 4:1, we pride ourselves on these dedicated individuals and their passion for the mission of Camp Brainstorm.

ELIGIBILITY AND CRITERIA

Any child with epilepsy and/or seizure disorder between the ages of 8 and 17 is eligible to apply to attend Camp Brainstorm. Camp Brainstorm is intended for physically abled children functioning at a developmentally appropriate level, and do not have severe physical and behavioral problems. The child must have a primary diagnosis of epilepsy and be on anti-seizure medications and/or physician-approved treatment therapy (i.e. Ketogenic diet, VNS, etc.) Our Camper Selection Committee will evaluate any secondary diagnosis.

Eligibility for selection to attend Camp Brainstorm is dependent on the completion of all forms, releases, and applications (Part 1 & Part 2). All applications are reviewed, and the Camper Selection Committee selects campers. Campers with completed and approved applications will be notified by either phone or email of the selection committee’s decision no later than May 1, 2025.

Should any information completed in this application be found to be falsified before and/or during the week of camp, the Epilepsy Foundation Central & South Texas reserves the right to deny acceptance and/or send the camper home. (For example, but not limited to excessive physical limitations, required care that does not reflect our staff ratio, behavior disturbances, etc.).

APPLICATION, DEADLINES AND SUBMISSION INFORMATION

To apply to participate in Camp Brainstorm, the parent/legal guardian must complete all parts of the application by the stated due date:

Part 1: Online Application (complete on or before May 1, 2025)

Section 1 - Camper Information
Section 2 - Emergency Health Information
Section 3 - Health History
Section 4 - Camper Care Information
Section 5 - Camper Profile
Section 6 - Acknowledgement of Behavior Policy
Section 7 - Reference Forms (for 1st Time Campers Only)

Part 2: Printed Application (Print, Complete, Sign & Return by mail, fax or email on or before May 1, 2025)
Camp Brainstorm Consent Form
Camper Treatment Consent Form
Medication Administration Form
Physical Exam Form
Camp Aranzazu Release Form
Shot Record (Upload to the application or attach to Part 2) if COVID Vaccine is received include a copy of the vaccination card (vaccine not required for Camp Brainstorm)
  Camp Physical Evaluation Form (Return by mail, email, or fax on or before May 1, 2025)

The Camp Brainstorm Physical Exam Form must be completed/signed by a physician.
Campers are encouraged to apply early. Your child WILL NOT be placed on the camper list until all requested documents are received.

Cell Phone Policy

Camp Brainstorm is a "screen-free" zone. A strict NO CELL PHONE POLICY will be enforced. If a camper is caught with a cell phone, the phone will be confiscated and placed in a safe location; the phone will be returned at "parent pick-up" on the final day.

Transportation To and From Camp

Transportation TO AND FROM CAMP MUST BE PROVIDED BY PARENTS/GUARDIANS. Parents are required to DROP OFF their camper in Rockport on Monday and PICK UP their camper in Rockport on Friday.

If you have any questions or require assistance with the application contact the Camp Team at Camp@EFCST.org or by phone (210) 653-5353.

The Epilepsy Foundation Central & South Texas provides equal opportunity to qualified persons without regard to race, color, creed, sex, or national origin.
I have read the eligibility and criteria information, including the cell phone policy and transportation updates.
Signature*

Clear

Camper's Name*

First NameLast Name
Name your child likes to be called:
Street Address*
City*
State*
Zip*
County*
Country
Parent's Primary Language*
Child's Primary Language*
Parent Primary Email Address*
Please list an email address you can check daily.
Date of Birth (MM/DD/YYYY)*
Gender*

MaleFemale
Age*
Cognitive Age*
Who is the child living with:*

Both ParentsMotherFatherOther
Does your family qualify for the free or reduced lunch program?*

YesNo
Ethnicity*
Shirt Size*
School Name*
School District*
Grade Next Fall*
How did you hear about Camp Brainstorm?*

Camp Transportation
Transportation TO AND FROM CAMP MUST BE PROVIDED BY PARENTS/GUARDIANS. Parents are required to DROP OFF their camper in Rockport on Monday and PICK UP their camper in Rockport on Friday.

If you have any questions or if you require assistance with the application contact the Camp Team at Camp@EFCST.org or by phone (210) 653-5353.
I agree to drop off and pick up my child at camp*

Yes, I will drive my child to camp.No, I cannot provide transportation to attend camp.
I agree to drop off and pick up my child at camp

Yes, I will drive my child to camp.No, I cannot provide transportation to attend camp.

Family Information
Mother's Name (or Legal Guardian)*

First NameLast Name
Home Phone*
Cell/Alternate Phone*
Email*
example@example.com
Alternate Email
example@example.com
Is Mother's Address the same as child?*

YesNo
*Mother's Address (If not same as child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Information
Father's Name (or Legal Guardian)*

First NameLast Name
Father Cell/Alternate Phone*
Father Home Phone (If different from Mother)
Is father's address the same as child?*

YesNo
Father's Email
example@example.com
Father Alternate Email
example@example.com
*Father's Address (If not same as child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information

In the event we are unable to contact the parent/legal guardian in an emergency, we will contact the primary designated emergency contact listed below. If parents will be out of town during the week of camp, ensure the emergency contacts are available and within driving distance of Camp Aranzazu.
Primary Emergency Contact
Primary Emergency Contact Name*

First NameLast Name
Primary Emergency Contact Relation to Camper*
Primary Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Emergency Contact Phone Number
Secondary Emergency Contact
Secondary Emergency Contact Name*

First NameLast Name
Secondary Emergency Contact Relation to Camper*
Secondary Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Emergency Contact Phone
Neurologist

Current Epilepsy Provider
Neurologist Name*

First NameLast Name
Neurologist Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Neurologist Phone*
Primary Care Physician/Pediatrician
PCP/Pediatrician Name*

First NameLast Name
Primary Care Physician/Pediatrician Name*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP/Pediatrician Phone*
Health Insurance
Does your child have health insurance?*

YesNo
Insurance Carrier *
Name of Policy Holder*
Policy Number*
Group Number
Policy Holder's Relation to Camper*

Allergies/Immunizations
Medication Allergies*
Please list any Medication Allergies if no allergies, write "None".
Food/Plant/Pollen/Insect Allergies*
Please list any Food/Plant/Pollen/Insect Allergies if no allergies write "None".
Immunization Record is required to attend Camp Brainstorm.

Campers must have had a Tetanus immunization within the last 10 years to attend Camp Brainstorm. Please list the date of the last Tetanus below and attach the camper's current shot record. The shot record may be uploaded or returned with a printed section of the application.
Date of last Tetanus Shot (Td, Dtap,DTP, DT)*

MonthDayYear
Date
Click here to upload Shot Record, include COVID vaccine card if your child has been vaccinated.

Cancelof

Acknowledgment of Behavior Policy
Please review the following behavior policy with your child.

Policy: Management of camper behavior problems at Camp Brainstorm.

Objectives: Provide a quality experience for all campers and volunteers. Decrease the risk of injury to campers and staff. Outline steps for management of extreme behavior problems.

Implementation:
The staff may identify problem behavior as conduct that is disruptive to others at camp or appears harmful to other campers. The following lists specific examples of those behaviors, followed by interventions the staff may take to provide a solution to the problem in order to reach the given objectives.

Examples of Minor Problems:
Teasing, calling names, talking back to staff, failure to cooperate, bringing a cell phone to camp, speaking out of turn, interrupting.

Examples of Major Problems:
Kicking, hitting, biting, bullying, throwing things, spitting, taking other’s belongings, pushing, etc.

Exceptions and Disclaimer:
The following course of action could be bypassed in the event of severe behavioral, emotional, or physical disturbances per the discretion of the Camp Director. Examples of such behavioral disturbances include but are not limited to threatening a camper/staff member or physically harming anyone; in any of these cases, the Director has the authority to send the camper home.

Strike I:
Intervening Staff: Cabin Counselors
Course of Action: Call the behavior to the camper’s attention. Inform the camper of the consequences, if the behavior continues (i.e., time out). Redirect the camper’s attention.

Strike II:
Intervening Staff: Cabin Counselors, Camp Director
Course of Action: Possible sit-out. The staff explains to the camper that because s/he has continued the behavior, s/he will sit out of the group for several minutes or the remainder of the activity. A call will be made to the child’s parent or legal guardian. The parent/guardian will be asked for assistance in redirecting the child’s undesirable behavior.

Strike III:
Intervening Staff: Camp Director, Physician
Course of Action: The child will be sent home. A child is given two opportunities for behavior modification. If the inappropriate behavior is repeated after the call home, the parent or legal guardian will be called to have the child picked up. If the parent or legal guardian cannot be reached within 1 hour, the emergency contact will be called. THE CHILD MUST BE PICKED UP WITHIN 6 HOURS AT THE FAMILY’S EXPENSE.
Digital signature*

Clear
I agree to the above Behavior Policy.

Application Part 2

You are almost done!
Eligibility for selection to attend Camp Brainstorm is dependent on the completion of all forms, releases, and application sections - Part 1 & Part 2. All applications are reviewed, and the Camper Selection Committee approves campers.

Part 2 of the application is available online at the link below. Complete and return Part 2 by email to Camp@EFCST.org. Please ensure that all initials and signature areas are completed.

Part 2 Link: https://www.campbrainstorm.com/wp-content/uploads/2025/01/2025-Camp-Application-Part-2.pdf

The link will also be available after the submission of the application on the confirmation page.

Please contact us by phone at (210) 653-5353 or by email at Camp@EFCST.org for any questions.
Camper Reference Forms

For NEW campers only.
To learn more about your camper, we require one school reference and one personal reference. The reference form should take just a few minutes to complete and is available online.

A school reference could be a teacher, nurse, or principal. A personal reference could be a church leader, a leader of an extracurricular activity (sports coach, etc.), or a family friend. Family members are not allowed to complete the reference forms.

References are required for 1st-time campers and are due by the application deadline of April 26, 2024.

The reference form is available online at https://form.jotform.com/231996308222155.
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APPLICATION DEADLINE MAY 1, 2025

Camp Transportation

Family Information

Father's Information

Primary Emergency Contact

Secondary Emergency Contact

Neurologist

Primary Care Physician/Pediatrician

Health Insurance

Health History

Allergies/Immunizations

Seizure Summary

Emotional Health

About Your Camper

Camper Profile

Acknowledgment of Behavior Policy

Application Part 2

Camper Reference Forms