2026 SMILE Camp Camper Application & Health Form

Date and Time June 15-19, 2026 | 8 a.m. - 3 p.m. EST

Location: North Florida School of Special Education 223 Mill Creek Rd, Jacksonville, FL 32211

Smile Camp is all about putting smiles on the faces of First Coast children with disabilities for over 50 years. Elementary school children with physical impairment, intellectual disabilities, autism and vision or auditory impairments are invited to attend this week-long day camp.

Smile Camp activities are planned and staffed by rising 9th-12th grade Girl Scouts. Counselors receive hands-on, intensive training and are paired with a campers each day.

Smile campers experience sing-alongs, games, art and more. Campers receive encouragement, physical assistance, and one-on-one attention from their Girl Scout counselors.

Safety counts! A Registered Nurse is on duty to handle emergencies and to administer prescribed medications.

Each camper will be required to submit a current photo, camper questionnaire, medical information and signed parent/guardian permission to attend camp. Prior to the start of Smile Camp, staff will speak with each camper’s parent/guardian to answer any questions you might have and seek input on ways to better work with your camper. Girl Scout Smile Camp staff will make reasonable accommodations, as required by law, to extend this opportunity to your child, provided that the accommodations do not impose an undue hardship on the ability of the 9th-12th grade Girl Scout staff.

Applications are accepted until all spaces are filled; additional campers will be placed on a waiting list.

Please fill out this form as completely and accurately as possible. The more information we have on your child, the better we can meet his/her needs and make the best camper-counselor pairing possible.

If you have any questions, please contact Sherri Johnson at gsbubba1964@gmail.com or text 904-710-2106

Camper Name*

First NameLast Name

Camper's Preferred Name/Nickname

Camper's Date of Birth*

MonthDayYear

Camper's Age*

MaleFemale

Camper's Current Weight*

Parent/Guardian Name*

First NameLast Name

Best Daytime Phone Number*

Area CodePhone Number

Evening Phone Number*

Area CodePhone Number

Parent Email*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Attach a Camper Photo*

What does your child enjoy doing while at home? Indoors? Outdoors?*

How does your child communicate with others? (Does he/she speak, use sign language or picture board, point or gestures?)*

Does your child have any emotional/behavioral problems that we need to be aware of? If so, please explain. a.) Are there certain items or situations that trigger an emotional outburst for your child? (loud noises, seeing an item they can not play with, ie: Ipod) b.) Does your child fixate on any one item? If so, how do you stop the fixation?*

Does your child use any adapted appliances or equipment? (Walker, stroller, wheelchair, AFO, etc.)*

Food: Does your child have any food or natural allergies? Does your child have any unusual food preferences or requirements?*

Is there anything that scares your child? If so, what usually calms your child down?*

Below is a condensed list of daily activities that occur at Smile Camp. Please rate and provide details on your child's abilities based on the following definitions:

Independent - Can do activity with verbal instructions and supervision
Semi-independent - May need some help with more complicated tasks
Supported - Needs help to complete most tasks
Dependent - Needs substantial physical guidance to participate in activities

Rows	Independent	Semi-independent	Supported	Dependent
Outdoor Games (Duck, Duck Goose, Tag, Relays)
Camp Activities (Catch, Blocks, Puzzles)
Dancing
Songs
Art Projects (coloring, painting, using glue or scissors)
Eating Lunch
Toileting
Dressing

Addtional comments, questions or suggestions:

If other than parent or guardian, person authorized to pick up my child after the event:

First NameLast Name

Please list any special instructions here.

YesNo

Camper's School*

Camper's Grade*

YesNo

If yes, please specify what disabilities are listed on their IEP

YesNo

If yes, please explain.

Past Illness *

Rows	Yes	No
Ear Infection
Asthma
Diabetes
Epilepsy
Heart Trouble
Convulsions
Drug Allergies (please specify below)
Hearing Impairment
Vision Impairment
Insect Sensitivity (please specify below)
Other Allergies (please list below)

If you marked "YES" for any of the above, please give approximate dates as well as any additional details needed.

MMR Immunization*

MonthDayYear

DPT Immunization*

MonthDayYear

Polio Immunization*

MonthDayYear

Tetanus Immunization*

MonthDayYear

MEDICATIONSMy child is presently taking: (list medications and reason for treatment)*

Date of childs last physical examination:*

MonthDayYear

Name of Child's Physician*

Phone Number of Child's Physician

Please enter a valid phone number.Format: (000) 000-0000.

Address of Child's Physician

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I agree

Authorization for Medication*

Rows	Yes	No
Neosporin First Aid Ointment
Tylenol
Epsom Salts
Hydrogen Peroxide
Insect Repellent
Benadryl Cream

I authorize use of First Aid Medication as indicated aboveI DO NOT authorize use of First Aid Medication as indicated above

YesNo

AUTHORIZATION TO TREAT A MINOR/ADMINISTER MEDICATION, the undersigned parent or legal guardian of the child listed above, who is a minor, do hereby authorize and consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment rendered by a licensed physician or under the general or special supervision of any member of the medical staff and emergency room staff of a duly licensed hospital in the United States and Canada.

I further authorize Girl Scouts of Gateway Council representative to select a medical doctor and/or hospital of his/her choice for the purpose of diagnosis or treatment of the above named minor. It is understood that this authorization is given in advance of any specific authority and power to render care which the aforementioned physician, in the exercise of his/her best judgment, may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the above named minor, but that any of the above treatment will not be withheld if the undersigned cannot be reached. This authorization is valid only for the treatment of emergencies when the undersigned is not reasonably available to give consent. This consent shall remain effective for one year from date listed below.

Signature

Date*

MonthDayYear

In the event of an emergency, if I cannot be reached, the following person is authorized to act on my behalf: Name*

First NameLast Name

Relationship to participant:*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Best Contact Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

I consent to allow all pictures taken of my child to be used for publicity purposes by the Girl Scouts of Gateway Council, Inc. I hereby indemnify and hold the above organization, its directors, officers and staff harmless against any and all claims of damages arising out of the taking or use of any pictures or names of myself or my minor child/children.

Signature