NEW Adaptive Backyard Bass Fishing

Welcome to Camp PossAbilities!
Camp PossAbilites is a Recreational Therapeutic Adaptive, and Inclusive Sports, Fitness, and Nutrition 90-minute program and activitivities created by the Christina Sullivan Foundation.

All sports programs and activities for children, youth, and adults with differing abilities are adapted to the athlete/participant's skill level. Buddy volunteers are partnered with our athletes/participants with differing abilities to enhance the experience of providing opportunities to create bonds of trust. This leads to inclusion empathy and compassion the Mission of the Christina Sullivan Foundation.

It's not about the sport. It's so much more. Josephine Sullivan, FOUNDER & CEO

Theraputic Benefits

- Stress Reliever - Builds Self Esteem - Creates Social Bonds - Exercise leads to a healthier lifestyle.

All equipment and supplies are provided.

HIPAA (Protected Medical Privacy Rule)
ADAPTIVE BACKYARD BASS FISHING
Therapeutic Benefits
- Learn the basics of casting and retrieving while playing a fun game with your Buddy!
- Backyard Bass is designed to teach the fundamentals of casting and retrieving with an adaptive or standard rod and reel without the dangers of actual fish hooks.
- The game also teaches users how to use the TEXAS PARKS and Wildlife Department (TPWD) outdoor Annual to identify their fish!
Information Athlete/Participant Profile
- Please upload a clear picture of participant. *

Cancelof
Please Upload a picture of you and or your athlete/participant TOGETHER. This will assist staff and buddy volunteers identify families/caregivers.*

Cancelof
Athlete/Participants First and Last Name*

First NameLast Name
Athlete/Participants Age*
Athlete/Participants Date of Birth*

MonthDayYear
Date
Grade/Graduated*
Relevant Diagnosis: Ex. Down Syndrome, TBI, dyspraxia, hemiplegia, Autism Spectrum Disorder (ASD), etc. *
The health information that you provide is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA). We can use your health information for purposes of treatment, payment and health care operations. Under HIPAA, you have the right to Request restrictions on how we use or disclose your health information in certain circumstances, including for treatment, payment or health care operations. We do not have to agree to your request unless you request restriction on disclosures to a health plan for purposes of payment or healthcare operations, and the health information relates to an item or service for which you, or another person on your behalf, have assumed full financial responsibility. If we do agree to your restrictions, we will be bound by our agreement except in limited circumstances, such as if there is an emergency.
Allergies:*
Parent/Guardian/Caregiver Information
Parent/Guardian/Caregiver First and Last Name *

First NameLast Name
Parent Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer(s)*
PARTICIPANT Medical Profile
YesNo
Vision Statement: Ex:(What would you like to see your participant achieve in the future?) Independence, sociability, following instructions, healthy eating choices, and exercise more...*
What works well for my participant: Example, multi-step instruction, hands-on support, verbal instruction, positive reinforcement, peer modeling, etc *
.
What does not work well for my participant? (Example, multi-step instructions, negativity. Yelling/loud voice, hand on instruction, etc*
.
Tell us your participant's hobbies/interests: Ex. Youtube, Disney Movies, singing, gardening, sewing, reading comic books, drawing, tennis, walking, swimming, etc.*
.
What is the best way to address your participant, and how do they prefer to communicate? Ex. First name, a nickname, ASL, verbal, etc*
.
My participant strengths Include: *
Tell us about your participants movement and mobility: Ex. ambulates (walks) independently, walks slowly, occasionally has issues with balance, individual uses a self-propelled wheelchair, individual uses a power wheelchair, etc.*
Tell us what your participant is working on: For example, social skills, attention to play in a group, increasing physical activity, learning a new sport, making new friends, strength, endurance, etc.*
GalvestonZoom is offered for meetingsNo, thank you.
Recreational Therapy Participants Information
Participant Name*

First NameLast Name
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian/Caregiver Phone Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Participants Medicare/Medicaid #*
Waiver Program: Community Living Assistance and Support Service (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCBS), Medically Dependent Children Program (MDCP), STAR+PLUS Home and Community-based Services (HCBS), Texas Home Living (TxHmL) and Youth Empowerment Services (YES).
Insurance Company:*
Name of Policy Holder:*
Policy Number:*
Insurance Company Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Are you receiving Recreational/Occupational Therapy Services*
Physicians Name:*
Physicians Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physicians Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Camp PossAbilities Scholarship Application
We want all of our participants to have the opportunity to experience Camp PossAbilities. If necessary, the Christina Sullivan Foundation will offer financial scholarships. Once you've finished this form, we'll reach out to you for more information. You'll need to provide all information on the Intake to receive an application.
WAIVER & RELEASE
By participating in any Christina Sullivan Foundation (CSF) program, event, clinic, or activity, I understand that physical activity involves inherent risks, including the risk of injury, illness, disability, death, or property damage.

I voluntarily assume all risks and release and hold harmless The Christina Sullivan Foundation, Inc., its officers, directors, employees, volunteers, facilities, sponsors, and partners from any and all claims arising out of participation, including claims of negligence, to the fullest extent permitted by law.

I confirm that the participant is physically and mentally able to safely participate.

I also grant CSF permission to photograph or record the participant and to use their name, image, or likeness for promotional, educational, or fundraising purposes without compensation.

If the participant is under 18, I certify that I am the parent or legal guardian and agree to these terms on behalf of the participant.
Signature*

Clear
Camp PossAbilities Adaptive Backyard Bass Fishing
prevnext( X )
Athlete/Participant
Donation Backyard Bass Fishing Registration

$35.00 Quantity
Item subtotal:$0.00

Total

$0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

Welcome to Camp PossAbilities!

ADAPTIVE BACKYARD BASS FISHING

Information Athlete/Participant Profile

Parent/Guardian/Caregiver Information

PARTICIPANT Medical Profile

Recreational Therapy Participants Information