Gary Brimer Sports Camp Registration

Gary Brimer Sport Camp: July 17-20 This camp offers all sport activites. It's a overnight camp. Activities run from 8am-9pm at night.

Athlete Information

Athlete's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Cell Number*

Area CodePhone Number

E-mail*

example@example.com

Gender*

MaleFemale

Age*

T-shirt Sizes*

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

Area CodePhone Number

E-mail*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Cell Phone Number*

Area CodePhone Number

Medications: routine medication times at camp are as follows: 7am, Noon, 5pm and 8pm. All medications being sent to camp must be in their original containter or blister pack. NO weekly planners.

List below are the "Over the Counter Medications" that are used at campfor minor illnessess. If you do approve of these medications please send other medications with campers that can be turn into the nurse.

Tylenol, Ibuprofen, benadryl Pepto Bismol,and Robitussin

List Current Morning Medication *

Please make sure you type in medication and times

List Current Noon, Afternoon and Medication *

Please make sure you type in medication and times

List Current Evening/BedtimeMedication *

Please make sure you type in medication and times

We are committed to making this experience a positive one for athletes of all ability levels(both physically and cognitively). Is there anything else you'd like to us to know about how your Athlete learns, moves, communitcates, etc., so we can make sure we are properly prepared for the them?

Does this athlete have anger or issues controlling emotions*

yesnoOther

If yes please explain *

Does the Athlete have Seizures?*

yesnoOther

If yes please explain

Does the Athlete have Allergies(food or Medications )*

yesno

If yes please explain

Does the Athlete use a wheelchair?*

yesno

Does the Athlete need assistance with walking or can they walk up stairs ?*

yesno

If yes please explain

Can the Athlete walk 5-10 miles a day*

yesno

Does the Athlete limited Speech?*

yesno

If yes please explain

Describe the best way to assist with athlete when communicating. How staff can get to them to follow instructions*

Again we aren't saying they can't participate if they do have issues with any of the above, we just want to know ahead of time so we can be better prepared so the experience is a great one for everyone involved. If you have any questions or reservations about applying, please email shaffer@somo.org

additional information

My Products*

Camp registration Fee $300.00

I have a scholarship$ Free

Must be approved by Susan Shaffer before submitting.

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country