Camp Participant Application Form

Camp Participant Application Form

Sept 12- 15, 2024
Personal Details
Full Name*

First NameLast Name
Nickname
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Gender*
Do you have a spinal cord diagnosis or a non spinal cord diagnosis?*
Spinal Cord Diagnosis*

Muscular DystrophySpinal Cord InjuryMSALSNoneOther
Level of Injury*
Complete or incomplete?*
Non-Sci Diagnosis*

Brain Injury SurvivorCerebral PalsyStroke SurvivorNoneOther
T-Shirt Size*
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Preferred Method of Communication

Phone CallText MessageEmail
Will you be attending the whole camp?*
If not, what days will you attend?*

ThursdayFridaySaturdaySunday
Transportation

There is a $50 fee for transportation. Transportation is full.
Will you require transportation?*
Will you be driving your own vehicle?*
Driver's Cell Phone*

Area CodePhone Number
Please provide vehicle year, make and model.*
Put None if needed
Vehicle license plate #*
How many seats are in the vehicle?
How many chairs can fit in the vehicle?
Can you transfer to a standard seat in a passenger car/van?
If no, please explain.
The camp has hills, assistive devices are recommended to be brought to camp. Please indicate what type of mobility aids you use:*

Electric WheelchairManual WheelchairScooterCrutchesWalkerSmartdriveFireflyOther
Do you use special equipment (e.g. lift, shower chair/seat, etc.)?*
If yes, what? (Please note you are required to provide and bring your own equipment.)*

Hoyer LiftRolling Shower ChairShower SeatTub BenchOther
Do you require a specialized mattress or other medical equipment while you sleep that requires access to a power outlet?*
Primary Emergency Contact Information

Please select someone who is not accompanying you on this trip. Note that we will also contact this person if we are unable to contact you about last-minute information related to your trip.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Relationship to Primary Emergency Contact*
Secondary Emergency Contact Information

Please select someone who is not accompanying you on this trip. Note that we will also contact this person if we are unable to contact you about last-minute information related to your trip.
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Relationship to Primary Emergency Contact
PCA/Volunteer/Guest Information

You may bring 1 caregiver and one family member or 2 family members. You may put none or N/A if you are bringing no one.
Will you be bringing anyone to camp with you? (Please note: volunteer caregivers available if needed. All volunteers are licensed healthcare professionals.)*
Can they sleep on a top bunk?
Please indicate your relationship to this guest (e.g. caregiver, family, friend, etc.)*
If the Caregiver is selected, please state the Agency below.*
or put N/A
PCA/Volunteer/Guest Full Name*

First NameLast Name
Gender*
Do you want him/her to sleep in the same cabin as you?*
PCA/Volunteer/Guest Phone Number*

Area CodePhone Number
PCA/Volunteer/Guest Email
example@example.com
PCA/Volunteer/Guest T-Shirt Size*
PCA/Volunteer/Guest Emergency Contact Name*

First NameLast Name
PCA/Volunteer/Guest Emergency Contact Email*
example@example.com
PCA/Volunteer/Guest Emergency Contact Phone Number*

Area CodePhone Number
Relationship to PCA/Volunteer/Guest*
Are you bringing a second overnight guest?*
If yes, please leave their name, number, and email below.
Health and Care Needs
Do you require assistance to complete your daily personal care needs?*
Will your PCA/Family member/Guest be providing all your assistance needs?*
Please indicate which tasks you will require assistance from Camp With A Ramp volunteers (NOT your PCA):*

BathingBowel CareFeedingGroomingLower body dressingUpper body dressingToiletingTransfersNo assistance neededOther
Please indicate your showering preference:*

Thursday PMFriday AMFriday PMSaturday AMSaturday PMSunday AMNo assistance needed
Do you need to be cathed in the middle of the night?*
Please indicate your bowel care preference:*

Thursday PMFriday AMFriday PMSaturday AMSaturday PMSunday AMNo assistance needed
Location Bowel care completed:*
If you need assistance with transfers, please indicate how you perform transfers.*
SERVICE DOGS ONLY: Will you be bringing a trained service animal with you?*
Any Comments or additional information you'd like to provide?
You cannot attend camp with any pressure sores. Please indicate any current SCI-related health problems:*

Autonomic dysreflexiaSevere spasticityNoneUrinary Tract InfectionOther
Are you currently in a doctor's care for any other health problems?*
If yes, to what medication(s) and describe the reaction(s):*
Are you allergic to latex or latex products?*
Are you allergic to any foods, animals, or insects?*
Please describe which foods, animals, or insects you are allergic to, or put NONE:*
Food Preferences
Do you require a special diet?*
What type of diet?*

NO DairyNO NutsVegetarianVeganOther
Does your 1st Guest require a special diet?*
What type of diet for 1st Guest?*

NO DairyNO NutsVegetarianType option 2Other
Please list any allergies your 1st Guest has.*
or type none
Does your 2nd Guest require a special diet?*
What type of diet for 2nd Guest?*

NO DairyNO NutsVegetarianType option 2Other
Please list any allergies your 2nd Guest has.*
or type none
Please indicate any medical conditions your 1st PCA/Family member/Guest has:*
or type none
Please indicate any medical conditions your 2nd PCA/Family member/Guest has:*
or type none
Do you have family/friends that will be attending events during the day ONLY?*
EMERGENCY MEDICAL TREATMENT-In the event emergency medical aid/treatment is required due to illness or injury, I authorize the Neuro and Brain Community Foundation representatives and the Camp With A Ramp Volunteers to assist with me or my minor children's emergency medical treatment and transportation if needed. |RELEASE OF LIABILITY--I hereby release the Neuro and Brain Community Foundation and Camp With A Ramp volunteers for any injury or damage I or my minor children may suffer as a result of my and their participation in the Camp With A Ramp event. |PHOTO RELEASE--I consent to and authorize the use and reproduction by the Neuro and Brain Community Foundation and the Committee of Camp With A Ramp of any and all photographs and any other audio-visual materials taken of me and my children during the event for promotional material, educational activities, fundraising, and exhibitions or for any other use for the benefit of the program without compensation to me. If you disagree, you will be given an armband so our photographers can identify you. Camp with a Ramp (CWAR) has put in place preventative measures to reduce the spread of Covid-19. However, CWAR cannot guarantee you, your children, or associated parties will not become infected with COVID-19. By signing this agreement I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or be infected by COVID-19 by participating in the event and agree not to hold CWAR or Neuro and Brain Community Foundation liable if infected I will only come to camp if I am symptom-free I will immediately let CWAR staff know if a resident in my home has tested positive or I have been exposed in any way before attending CWAR event.*
Signature*

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Guest Meal Breakfast$15.00
Day visitor coming just for breakfast

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Guest Meal Lunch$15.00
Day visitor coming just for lunch

Quantity

Guest Meal Dinner$15.00
Day visitor coming just for dinner

Quantity

Camper$400.00

Guest/Family Camper$400.00

Quantity

Caregiver Camper$200.00

Scholarship Camper$150.00
Please only click this option after your scholarship inquiry has been approved.

Total $0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Camp Participant Application Form

Personal Details

Transportation

Primary Emergency Contact Information

Secondary Emergency Contact Information

PCA/Volunteer/Guest Information

Health and Care Needs

Food Preferences