Sibling Camp Application for Elks Camp Grassick

Sibling Camp Application for Elks Camp Grassick

Application for the school aged sibling of a child with a physical and/or intellectual disability or other significant support needs.
Permission

I, as parent/guardian of this individual, 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 from this individual's school, teachers, therapists, or other persons/organizations 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.
Signature*

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Identifying Information
Name of Applicant*

First NameLast Name
Preferred Name or Nickname
Gender*
T-Shirt Size*
Birthdate*

MonthDayYear
Age as of Camp Start Date*
Name of Parent or Guardian #1 (Primary Contact)*
Relationship to Camper:*
Parent/Guardian Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
Home Phone Number:
Please enter a valid phone number.
Work Phone Number:
Name of Parent or Guardian #2 (Secondary Contact)
Relationship to Camper:
Parent/Guardian Email
example@example.com
Is this address the same as Parent/Guardian #1?

yesno
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:
Home Phone Number:
Please enter a valid phone number.
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.

Information from Camp
Contact: How would you as parents/guardians 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.
School Information
Name of School Student is Attending*
Grade*
Does this individual have a diagnosis or support need? If so, please describe.

Sibling/Family Information
Name of the Sibling with a Disability or Significant Support Need*
Diagnosis or Description of Disability*
ex. Cerebral Palsy, intellectual disabilities, chromosomal abnormality
Please list the adults living in the home and their relationship to this individual.
Number of Siblings*
Number of children living in the home*
Please describe this applicant's relationship with their sibling with a disability. (How do they interact? Does this applicant help with cares? Are they ever responsible for their sibling in a parent/guardian's absence? Etc.)*

Social Study
Please describe a little about this applicant's independence. Is it average for age or higher or lower than average for age?*
Please describe this applicant's maturity level. Is it average for age or higher or lower than average for age?
Please describe how this applicant relates to others in the home, school, and community environments?
Please list a few interests or hobbies of this individual.*
Is this individual afraid of anything? Do they have nightmares? Please describe. Is there anything that comforts them?*
Has this individual ever been to an overnight summer camp? How do you feel that this individual would adjust to being away from home and in a camp environment?*
Is there any other information that you feel we should know about this individual?

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 - $150Sibling Camp - $150
I hereby agree to pay $ blanks for this individual to attend Elks Camp Grassick.
Signature

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If you have any questions, please feel free to call camp at 701-327-4251.
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Sibling Camp Application for Elks Camp Grassick

Permission

Identifying Information

Information from Camp

School Information

Sibling/Family Information

Social Study

Medical Form/Health History

Identifying Information

Epilepsy and/or Seizure History

Allergies & Dietary Restrictions

Vaccines

Medications

Health History

Elks Camp Grassick Fee Agreement