Circle of Friends Camp Application

Circle of Friends Camp Application

This application is detailed and may take 45-60 minutes to complete.
Before you begin, please gather:

✔️ Emergency contact information
✔️ Medical history and diagnoses
✔️ Prescription medication names, doses, and schedules
✔️ Pharmacy labels (recommended)
✔️ Insurance and physician information
✔️ Allergy and dietary information
✔️ Recent photo of applicant
✔️ Uploaded documents (if applicable)

You may save and return later if needed.
Yes

Circle of Friends Camp Application
Name of Person filling out this form.*

First NameLast Name
Relationship to Applicant*

1. Applicant Information
Applicant Name*

First NameLast Name
Please upload photo of applicant.*

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Applicant Gender*
T-shirt Size*
Applicant Date of Birth*

MonthDayYear
Date
Applicant Age at time of Camp*
How old will the applicant be when they attend camp?
Applicant Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian Status*
2. Guardian Information
Guardian 1 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

3. Emergency Contact

If guardian(s) cannot be reached
Emergency Contact 1*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

7. Disabilities, Limitations, & Support Needs
Applicant's Diagnosis (if applicable)
Please describe any disabilities, limitations, and support needs in your own words.
File Upload - Attach additional care plans, IEPs, behavior plans, or notes if helpful.

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13. Medical Considerations & Health Information
History of seizuresPhotosensitive seizuresStroke HistoryTraumatic brain injuryHistory of concussionsOther neurological condition
Regular Seizure Medication
Emergency / rescue medication
Dosage
Route
Instructions Staff should follow
Please describe seizure type, frequency, known triggers, and warning signs.
Pleaser explain stroke history.
Please explain traumatic brain injury.
Please explain history of concussion.
Please explain other neurological condition.

Heart health concernsHigh blood pressureLow blood pressureDizziness or fainting eposodesArrhythmia / irregular heartbeatPacemaker / implanted cardiac deviceHistory of heart surgeryCheck pain with activityExercise restriction of special precautions
Please explain heart health concerns
Please explain dizziness or fainting episodes.
Please explain arrhythmia / irregular heartbeat.
Please explain pacemaker / implanted cardiac device.
Please explain history of heart surgery.
Please explain chest pain with activity.
Please explain exercise restrictions or special precautions.

Asthma or reactive airway diseaseUses inhaler or nebulizerUses CPAP or other breathing support at night
Please explain asthma or reactive airway disease triggers
ApplicantStaffNurse

Food allergies (see Dietary section)Environmental allergies (bees, pollen, etc.)LatexHistory of anaphylaxisCarries EpiPen
Self-administerRequires staff assistance

GERD / refluxChronic constipationProne to vomitingSwallowing difficulties or aspiration riskTube Feeding
Tube Feeding Type
(G-Tube, J-Tube, etc.)
Tube Feeding Schedule

Type 1 DiabetesType 2 Diabetes
YesNo
YesNo
Hypoglycemia unrelated to diabetesThyroid disorderOther metabolic condition
Please describe other metabolic condition

Sensitive skin / eczemaProne to heat exhaustion or heat strokeDifficulty regulation body temperatureSun sensitivity

Chronic PainMuscle spasticity or tightnessJoint instability or dislocationsRecent injuries affecting activity

Compromised immune systemRecent surgery or hospitalization (past 6 months)

Other Medical Information
YesNo
Other medical conditions we should be aware of

Emergency Care Notes
Anything staff should know to keep the applicant safe an supported?
Applicants Primary Care Physician

First NameLast Name
PCP Phone
Please enter a valid phone number.Format: (000) 000-0000.

14. Dietary Needs

Kitchen staff and Circle of Friends staff will be provided with a list of food allergies and special dietary needs along with a camper photo.
Follows a diabetic dietRequires carbohydrate countingRequires portion-controlled mealsFood texture modifications (soft foods, pureed, chopped, meat cut, etc.)Feeding schedule restrictions (e.g., specific meal/snack timesCeliac DiseaseNothing by Mouth G-tube ExclusiveNutrition by G-tube pleasure feeding only
Please explain applicant's diabetic diet
Please explain applicant's portion controlled meals
Please explain applicant's food texture modification
soft food, pureed, chopped, meat cut
Please explain feeding schedule restrictions
specific meal or snack times

Nut allergiesShellfish allgeriesGluten or wheat sensitivityLactose or dairy intoleranceFood dye sensitivitiesOther food allergy or sensitivity
Please explain applicant's nut allergy
Please explain applicant's shellfish allergy
Please explain applicant's Gluten or wheat sensitivity
Please explain applicant's lactose or dairy intolerance
Please explain applicant's food dye sensitivity
Please explain applicant's other food allergy or sensitivity

Requires full assistanceRequires prompting to eat/drinkNeeds assistance with utensilsRequires adaptive feeding tools (spoon, cup, plate, etc.)
Please explain adaptive feeding tools

Requires scheduled fluidsRequires thickened fluids
Nectar-thick (like heavy juice or thin syrup)Honey-thick (like honey, coats a spoon)Pudding-thick (thick enough to eat with a spoon, does not pour)Other / Special instructions
Please include special instructions here.
YesNo
Please list each supplement, dosage, and schedule.
Other feeding instructions

Snacks, Drinks & Nut-Free Policy
Campers may bring snacks or drinks from home, but it is strongly discouraged. We encourage families to rely on camp-provided meals and snacks to ensure proper nutrition, safety, and consistency.

If snacks are brought from home, please inform staff during check-in and give the snacks to your camper’s assigned group leader once you have checked into their lodging assignment. This helps protect all campers on the premises who may have allergies or dietary restrictions.

Nut-Free Policy

Lost Valley is a NUT-FREE facility.
No products containing peanuts, tree nuts, or nut-derived ingredients are allowed on the premises at any time. This includes snacks, drinks, supplements, or other food items.
I understand the camp’s guidance regarding snacks and drinks from home and the Nut-Free policy.I understand that any food allergies or dietary restrictions I have listed for my camper, along with a current photo, may be shared with Circle of Friends and Lost Valley staff and posted in the kitchen for staff reference only (not visible to campers) to support camper safety.
Guardian/Applicant (if own guardian) Please enter your initials to confirm you have reviewed and agree to the statements above.*

15. Medication & Over-the-Counter Authorization
Applicant Height*
Applicant Weight*
Medication allergies (if any)
Topical Products Permission
YesNo
YesNo
YesNo

Prescription Medication
YesNo
Enter Prescription Medication Here (including any entered before this step)*

Authorization & Acknowledgement
I give permission for Circle of Friends Camp designated medical personnel or trained staff to administer the over-the-counter medications and topical products I have approved above, in accordance with standing camp health protocols and manufacturer-recommended dosing, during the dates listed August 3rd through August 14th, 2026.

I understand that Circle of Friends Camp is not a licensed medical facility and that over-the-counter medications are administered in good faith based on the information provided.
Acknowledged
Applicant / Guardian Name*

First NameLast Name
Guardian/Applicant (if own guardian) Signature*

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16. Immunization/Vaccination Information

Circle of Friends Camp does not require campers to be fully immunized; however, families acknowledge that participation in a group setting carries inherent health risks, including exposure to communicable illnesses.
Applicant is current on immunizations as recommended by their healthcare provider.Applicant is not current on all immunizations.
Medical exemption (documented by provider)Religious exemptionPersonal/philosophical preferencePrefer not to answer
Acknowledged

17. Medical Insurance Information
Primary Medical Insurance Provider*
Policyholder Name*
Policy Number*
Group Number (If applicable)
Insurance Phone Number (From Card)
YesNo
If yes, secondary insurance provider
Please attach a copy (front and back) of applicant's insurance card here.

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Acknowledged
Guardian/Applicant (if own guardian) Initials*

18. Agreement & Accuracy of Information
I affirm that, to the best of my knowledge, the information I have provided on this application is complete and accurate. I understand that it is my responsibility to notify the Circle of Friends Camp director of any changes to the camper’s health, medications, or other relevant information prior to the start of camp.

Camp Safety & Code of Conduct
Circle of Friends Camp is committed to providing a safe, welcoming, and positive environment for all campers and staff. To help ensure everyone’s well-being, the camp is a recreational drug-free, alcohol-free, nicotine-free, pornography-free, and unauthorized weapon–free zone, including firearms, knives, and other weapons. We reserve the right to dismiss any camper whose behavior is unsafe, disruptive, or harmful to themselves or others, at our discretion. In such cases, refunds may not be provided.
Applicant Name*

First NameLast Name
Guardian Name

First NameLast Name
Guardian/Applicant (if own guardian) Signature*

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19. Camper Goals & Talent Night
What would a successful week at camp look like for your camper?*
During the week, we host an optional Talent/Karaoke Night where campers may share something they enjoy in whatever way feels comfortable to them. This could include singing, playing an instrument, telling jokes, demonstrating a skill, or participating with support.

Participation is completely optional, and campers are welcome to change their mind at any time.

If your camper already has a favorite song, activity, or talent they enjoy sharing, feel free to let us know. This does not need to be decided now to participate, but it helps us be as prepared and supportive as possible.
If you know what your camper might like to do for Talent Night, please share.

20. Pick-up Authorization
Instructions:

·         Leave these boxes blank if they do not apply to
your situation.

·         Camp staff are legally required to follow the
instructions provided in these sections.

·         All authorized individuals must present valid
photo ID at pick-up.

If an ID is not available or a person is not listed, local law enforcement will be contacted to ensure camper safety.
Do not release to.
Only release to.

21. Consent & Agreement
RELEASE, WAIVER OF LIABILITY, AND INDEMNIFICATION AGREEMENT

I understand and acknowledge that Circle of Friends Camp is a ministry program operated by PB’s Friends Inc., in partnership with Atlanta Full Gospel Church, and is conducted at Lost Valley Bible Camp. I further understand that the applicant/camper will participate in activities, programs, transportation, lodging, and events provided by or occurring at Lost Valley Bible Camp.

I acknowledge that participation in camp activities—including, but not limited to, recreational activities, group events, outdoor activities, transportation, meals, and daily living supports—involves inherent risks, including the risk of personal injury, illness, emotional distress, property damage, or death. I understand that these risks may be increased due to the physical, developmental, behavioral, medical, or cognitive disabilities of the applicant/camper. I affirm that I have voluntarily chosen to allow the applicant/camper to participate in Circle of Friends Camp with full knowledge of these risks.

RELEASE AND WAIVER

To the fullest extent permitted by law, I hereby release, waive, discharge, and covenant not to sue: PB’s Friends Inc., Atlanta Full Gospel Church, Lost Valley Bible Camp, any affiliated churches, organizations, or ministries, their respective trustees, officers, directors, board members, pastors, employees, medical staff, counselors, volunteers, agents, and representatives (collectively referred to as the “Released Parties”) from any and all claims, demands, actions, causes of action, losses, damages, costs, or expenses of any kind, whether known or unknown, foreseen or unforeseen, arising out of or related to the applicant/camper’s participation in Circle of Friends Camp, including but not limited to claims for negligence, personal injury, illness, emotional distress, property damage, or wrongful death.

INDEMNIFICATION AND HOLD HARMLESS

I further agree to defend, indemnify, and hold harmless the Released Parties from and against any and all claims, liabilities, damages, losses, costs, and expenses, including reasonable attorneys’ fees and court costs, arising from or related to:

· The applicant/camper’s participation in camp activities

· Any medical condition, behavioral issue, or disability of the applicant/camper

· Any inaccurate, incomplete, or omitted information provided by me

· Any acts or omissions of the applicant/camper

This indemnification obligation shall apply even if such claims arise in whole or in part from the negligence of the Released Parties, except to the extent prohibited by applicable law.

MEDICAL CONSENT

I authorize Circle of Friends Camp staff, volunteers, and leadership to administer basic first aid and to obtain emergency medical treatment for the applicant/camper as deemed necessary. If I cannot be reached, I authorize transportation to a medical facility and consent to any medical treatment a licensed physician deems necessary. I understand that all medical expenses are my sole responsibility.

PHOTO & MEDIA RELEASE

I grant permission for the use of photographs, video, or audio recordings of the applicant/camper for ministry, promotional, educational, and fundraising purposes, including print and digital media, without compensation.

ACKNOWLEDGMENT & SEVERABILITY

I acknowledge that I have read and fully understand this Release, Waiver of Liability, and Indemnification Agreement. I understand that by signing this document, I am giving up substantial legal rights, including the right to sue. I sign this agreement freely and voluntarily. If any portion of this agreement is found to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.
Applicant Name*

First NameLast Name
Guardian Name

First NameLast Name
Guardian/Applicant (if own guardian) Signature*

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23. Camp Fees & Levels of Care
Camp fees are based on each camper’s individual support needs and are determined after the application has been received and reviewed by Circle of Friends staff.

The following descriptions outline the levels of care used to help determine appropriate placement. Families are encouraged to review these guidelines to gain a general sense of where their camper may fall; however, final determination of level of care is made by Circle of Friends Camp.

Camp fees correspond to staffing ratios and support requirements. If a camper’s level of care changes from one year to the next, fees may be adjusted accordingly. Families will be notified if a change in level of care or fee is necessary. Final level-of-care determinations are made at the sole discretion of Circle of Friends Camp, based on application information and staff observation, to ensure the safety and well-being of the camper, other campers, and staff
Level 1: Standard Support (3–4 Campers per Staff) $675

The camper is able to perform most Activities of Daily Living (ADLs) independently.

The camper takes 0–4 medications per day and does not have significant ongoing medical concerns that require continuous monitoring or intervention. The camper is independent with eating or may require minimal verbal prompting and/or light physical assistance (such as cutting food). The camper is independent with toileting and showering, with minimal verbal prompts and/or assistance.

The camper is able to follow group instructions (such as staying with their group and remaining on task) with minimal verbal prompting. The camper is able to clearly communicate needs to staff with minimal effort.

Note: Campers at this level will remain supervised by staff at all times. While campers are not fully independent, additional staff support is available as individual needs arise.
Level 2: Moderate Support (2 Campers per Staff) $795

The camper requires some physical assistance while remaining independent in other areas of care.

The camper takes 5–8 medications per day and may have mild or well-managed medical concerns that do not require continuous monitoring. The camper may need assistance accessing food at meals and may require specialized dietary protocols (such as pureed foods). The camper may require minimal toileting assistance (such as wiping) but does not require diapering.

The camper may require verbal prompting, redirection, or support to remain focused on tasks or to practice coping skills. The camper may be non-verbal or minimally verbal and may use alternative methods of communication. The camper may use mobility devices and is able to operate them primarily independently, with staff assistance as needed.
Level 3: One-to-One Support (1 Camper per Staff) $950

The camper requires one-to-one assistance at all times due to medical, behavioral, or safety needs.

There are no medication number limitations; however, Circle of Friends Camp is not a licensed medical facility, and all medications must be able to be administered safely by trained camp staff according to provided instructions. Campers who require medical treatments such as feeding tubes, severe seizure monitoring, or insulin-dependent diabetes requiring regular injections are automatically assigned Level 3 care.

The camper may require full assistance at mealtimes and with most or all hygiene needs, including toileting, diapering, and bathing. The camper may require staff assistance for all camp activities, may be dependent on mobility devices, and may be considered a flight risk.
Behavioral & Emotional Health Considerations

In addition to medical and physical needs, Circle of Friends Camp reserves the right to assign Level 3 care based on behavioral or emotional health considerations that require continuous supervision to maintain safety.

These may include, but are not limited to:

Aggressive behaviors toward self or others
Self-injurious behaviors
Severe impulsivity or lack of safety awareness
Elopement or flight-risk behaviors
Significant emotional dysregulation, anxiety, or trauma-related responses requiring constant adult support.
Level 1 - Standard Support (3-4 campers per staff)Level 2 - Moderate Support (2 campers per staff)Level 3 - One-to-One Support (1 camper per staff)
Optional comments or clarification
Acknowledged
Guardian/Applicant (if own guardian) Initials*
Circle of Friends Camp is not a medical facility. While staff are trained to provide appropriate care and supervision, the camp does not provide medical treatment beyond routine support and emergency response procedures.
Should be Empty:

Circle of Friends Camp Application

Circle of Friends Camp Application

1. Applicant Information

2. Guardian Information

3. Emergency Contact

4. Camp History & Preferences

5. Home Life & Daily Routines

6. Sleep & Overnight Needs

7. Disabilities, Limitations, & Support Needs

8. Vision, Hearing, & Communication

9. Personal Care

10. Mobility & Equipment

Wheelchair Details

11. Behavior, Emotional, & Mental Health Supports

12. Sensory Sensitivities

13. Medical Considerations & Health Information

Other Medical Information

Emergency Care Notes

14. Dietary Needs

Snacks, Drinks & Nut-Free Policy

15. Medication & Over-the-Counter Authorization

Topical Products Permission

Permission for Over-the-Counter Medications

Prescription Medication

Authorization & Acknowledgement

16. Immunization/Vaccination Information

17. Medical Insurance Information

18. Agreement & Accuracy of Information

19. Camper Goals & Talent Night

20. Pick-up Authorization

21. Consent & Agreement

22. Payment Method & Funding Information

23. Camp Fees & Levels of Care