Youth 2 Seek Camper Profile
Camper Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Age
Gender M/F
Male
Female
Height
Wight
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Name
Best Contact Phone Number
Father's Name
Best Contact Phone Number
Best Contact Email
Emergency Contact
Emergency Contact Relationship (other than parent)
Best Phone Number for Emergency Contact
Tshirt Size
Please Select
Youth Small
Youth Med
Youth Large
Adult Small
Adult Med
Adult Large
Adult XL
Adult XXL
Adult XXXL
Other
Back
Next
Help Us Get to Know Your Child
Name
First Name
Last Name
Name and ages of Family Members
Primary Diagnosis (please describe)
School Graduated From
How does Camper Communicate?
Describe Camper's Motor Skills:
Can Camper... Check all that apply
Button
Lace
Tie
Comb Hair
Shampoo
Undress
Does Camper need assistance getting around? If yes, what kind? If no, leave blank
Has Camper every been away from home alone?
Yes
No
If yes to above question, where?
What's your campers favorite activities?
What things does your camper not like or is afraid of?
How does your camper get along with adults?
How does your camper get along with other children/youth?
Are their behavior problems or concerns that you have specific ways of handling? Would you like for us to continue this? We ask because we feel that being consistent in our expectations of the camper is only fair.
Back
Next
Camper's Self Care
Camper Name
First Name
Last Name
Shower Time?
Camper can shower independently.
Camper can shower independently but needs help getting the water the right temp.
Camper can shower but needs supervision.
Camper must be bathed.
Camper needs props or devices for in the shower.
Dressing Habits
Camper can dress independently
Camper needs help selecting clothes
Camper needs supervision getting dressed
Totally dependent
Please add anything you would like us to know about camper's dressing habits
Brushing Teeth
Camper can brush teeth independently
Camper needs assistance/directions to brush teeth.
Toileting
Does camper use any of the following:
Glasses
Hearing Aids
Wheelchair
Walker
Communication Device
Dental Appliances
Leg Braces
Please add any other special equipment or special instructions (ie. can leg braces be removed? if so, when?)
FEMALE CAMPERS ONLY
Camper can manage menstrual periods independently
Camper needs help with her menstrual periods
Please list exactly what help camper needs when on her period.
Washing Hands
Camper can independently wash hands
Camper needs supervision to wash hands
Camper needs help washing hands
Special words or signs that camper uses to indicate toilet needs?
My camper would like to be in the same cabin as (please note, this is not a guarantee)
Sleep Habits
Camper sleeps well when away from home
Camper needs bed rails.
Please list and helpful bedtime routine info:
Eating Habits
Camper can eat independently
Camper needs help eating
Chokes easily
Chews well
Totally dependent
Camper is Tub Feed
Camper eat NOTHING by mouth
If camper needs help eating, please explain in detail what help is needed.
Please list specific foods camper likes
Please list specific foods dislike
Please list any food allergies (this question will be asked twice, once for the counselor info and once for the nurse info)
Back
Next
Seek Camp Medical Form
Camper Name
First Name
Last Name
Physician Name
Physician Phone Number
Insurance Carrier/Plan Name
Policy #
Group #
Name of Policy Holder
Date of Birth of Policy Holder
Insurance Phone #
Back
Next
Health History
Camper Name
First Name
Last Name
Please list any FOOD allergies and Reactions & Treatment
Please list any MEDICAL Allergies and Reaction & Treatment
Please list any OTHER Allergies and Reaction & Treatment
Camper has had chicken pox or varicella vaccination.
Yes
No
Camper has had mononucleosis in the past 12 months
Yes
No
Camper has a history of illness, injury, or surgery which will affect participation.
Yes
No
If yes to the previous question, please explain.
Chronic Concerns (Please check all that apply)
This camper has NO chronic health concerns and is capable of full participation at camp.
Asthma (even if inhaler is only used occasionally)
Frequent ear infections
Migraine Headaches
Enuresis (bed-wetting)
Depression, ADD, ADHD, Oppositional Behavior Disorder
Eating Disorder
Diabetes
Seizures
Other
If click on any of the above, please provide any helpful information for care.
Back
Next
Parent Authorization to Administer Medication
Seek Camp personnel MUST have written parental consent in order to administer over-the-counter medication (OTC). Generic equivalents maintained by the nurse may be used in place of brand name. OTC medications will be administered sparingly and according to standardized dosing instructions when indicated to make your child more comfortable. Please check the OTC medication your camper may be given if needed.
Camper Name
First Name
Last Name
Pain Reliever/Fever Reducer
Constipation/Diarrhea
Cold/Congestion/Allergy
Skin
Antiseptics
Eye Wash
Indigestion
By typing my name below and signing in the signature box, I hereby authorize the nurse to administer medication designated on this form in accordance to standardized dosing instructions. I understand that any nurse who administers these medications according to proper dosages shall not be held liable for damages as a result of an adverse reaction to the medications administered.
Signature
Morning Medication (if any)
Lunch/Afternoon Medication (if any)
Dinner Medication (if any)
Bedtime Medication (if any)
Back
Next
Paperwork I will need before camp:
Name
First Name
Last Name
Paperwork to get signed and submit:
Here are the forms I need either notortized or a doctor's signature. Please get these turned in by April 15th. You can email them to me at youth2seekcamp@gmail.com or snail mail to Youth 2 Seek Camp 2332 County Road 377, Van Alstyne, Tx 75495
I understand that I need to print the above paperwork to get notarized and/or signed
Please upload a picture of the FRONT of your insurance card here.
Please upload a picture of the BACK of your insurance card here.
Scan QR Code below if you would like to pay via paypal. Camp is $550.00
Checks can be made payable to Youth 2 Seek Camp and mailed to 2332 County Rd 377, Van Alstyne, TX 75495
Submit
Should be Empty: