Welcome to our all new
Online Registration Form for Returning Campers. Before you start to fill in this form, click on our
Camper Instructions link and read through that page. There is a lot of important information you need to consider before you register.
Please select which week you would like to attend Camp BASIC: (*)
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Personal Information
Camper's Name: (*)
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Nickname:
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Street Address: (*)
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City: (*)
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State: (*)
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Zip Code: (*)
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Day Phone: (*)
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Evening Phone: (*)
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E-mail Address: (*)
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What is the Camper's T-Shirt Size?
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Camper's Age: (*)
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Camper's Birth Date: mm/dd/yyyy (*)
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Gender: (*)
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Residence: (*)
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Parent or Caregiver's Name: (*)
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Parent/Caregiver's Address (*)
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Parent/Caregiver's City (*)
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Parent/Caregiver's State (*)
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Parent/Caregiver's Zip (*)
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Parent/Caregiver's Day Phone (*)
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Parent/Caregiver's Evening Phone (*)
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Insurance Information
For emergency purposes, ALL Campers MUST complete this section. Include INSURANCE CARRIER and POLICY NUMBER or Medical ASSISTANCE NUMBER.
Medical Assistance Number: (*)
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Insurance Carrier: (*)
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Policy Number: (*)
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Emergency Contact #1
The Emergency Contact is the person we will contact if the parent/caregiver cannot be reached.
Emergency Contact 1 Name: (*)
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Emergency Contact 1 Relationship to Camper (*)
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Emergency Contact 1 Day Phone:
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Emergency Contact 1 Evening Phone (*)
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Emergency Contact #2
Emergency Contact 2 Name: (*)
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Emergency Contact 2 Relationship to Camper (*)
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Emergency Contact 2 Day Phone: (*)
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Emergency Contact 2 Evening Phone (*)
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Is the camper his/her own guardian?
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If no, name of Gardian:
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Religious Background
Church Affiliation:
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If you checked "Other" above, please indicate:
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Church's Name:
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Pastor's Name:
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Is this Camper baptized: (*)
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Is this Camper confirmed: (*)
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Does this Camper attend church services regularly?
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Does or has this Camper attended religious instruction classes? (*)
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If yes, please describe the type of classes (Sunday School, Confirmation Class, Bible Study, etc):
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Leasure Time Activities
Please list this Camper's Hobbies: (*)
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Pease list this Camper's Special Interests (*)
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Please indicate any Likes or Dislikes (this can include likes or dislikes concerning work, housekeeping, activities, etc. ): (*)
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Disability
Please name and describe any of this Camper's developmental disabilities: (*)
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Please name and describe any secondary disabilities of this Camper (if any, including diabetes):
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Cognitive Ability/Developmental Delay
Please select the appropriate button that best describes this Camper's cognitive ability/developmental delay: (*)
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Mobility
Can this Camper walk? (*)
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Walking Speed:
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Is a wheelchair needed for long distances? (*)
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If Yes, Please bring a wheelchair to Camp
Any additional information concerning this Camper's mobility?
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Hight: (*)
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Weight (*)
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Speech & Communication
Communication (*)
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Ability to read? (*)
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Ability to write (*)
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Ability to talk? (*)
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If speech is severely limited, what language device (sign language, picture book, etc) is used? (Please bring)
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Please list any commonly used signs or gestures:
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Personal Hygiene & Grooming
What kind of assistance does this Camper need from us in the following areas?
Bathing (*)
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Shaving (*)
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Brushing Teeth (*)
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Brushing Hair (*)
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Menstrual Care (women)
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Dressing (*)
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If some assistance is needed for dressing this Camper, please explain:
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Sleep Patterns
What is this Camper's sleep pattern like?
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If abnormal, please explain:
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Bladder & Bowel Control
Does this Camper use the toilet independently? (*)
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Please explain the assistance this Camper needs in using the toilet:
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Incontinent: (*)
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Bowel: (*)
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Bladder: (*)
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Does Camper wear Depends? (*)
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If Camper wears depends, when?
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Is there any additional information we should know about this Camper's bladder / bowel control?
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Shower
Does this Camper need a shower chair? (*)
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Does this Camper need a hand-held shower? (*)
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Behavior
Please check all that apply: (*)
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If you checked "other"please exlpain: (*)
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If this Camper is prone to wander, please describe the behavior and give suggestions for managing it:
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Describe approaches to be used with difficult behavior. (Camp staff volunteers their time and are not specifically trained to deal with challenging behaviors. If this is an area of concern for an individual, please contact the Director of the week you are requesting, with any behavioral concerns.): (*)
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Please note any additional information that may assist our staff to be fully prepared to serve this camper during his or her stay this summer:
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Activities
Swimming: (*)
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Please list any activities this Camper should not participate in, or may fear (swimming, nature center, parties, etc): (*)
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Diet & Eating
Does the Camper eat a regular diet? (*)
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What kind of diet restrictions does this Camper have:
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What kind of special dietary needs does this Camper have:
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Can this Camper have seconds? (*)
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Is this Camper diabetic? (*)
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If Camper is diabetic, what's the normal blood sugar range:
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Can this Camper deviate from their diet, or portions of it, during camp? (*)
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If yes, specify:
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Staff will make every effort to adhere to diets. However, they may not be able to keep strict reducing diets.
Does this Camper need assistance eating? (*)
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If Camper needs some assistance eating, please explain:
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Allergies
Any Allergies (*)
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If this Camper has any allergies, please list the allergies and describe the reactions:
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Seizure Disorders
Does this Camper have seizures? (*)
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What type of seizures does this Camper have?
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How often does this Camper have seizures?
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Date of last seizure:
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During a seizure, what precautions should the camp staff be aware of?
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Medical Care
If needed, which medicatons are we allowed to give to this Camper?
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Please check the box if this Camper experiences any of these conditions frequently:
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If you checked on any of the above frequent conditions, please describe how each of these conditions are treated at home:
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Any additional medical care information:
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Legal Releases
The following releases
must be checked and dated by the Camper if they are their own Guardian, or the Camper's Guardian. If the releases are not checked, the Camper will not be permitted to attend Camp.
Photo/Public Relations Consent and Release
I understand that Camp BASIC may wish to use my/my camper's name, photograph and / or stories with its work and that it needs appropriate consent to do so. Pictures may be taken for the purpose of sharing with the group, for sharing with area churches, the community and on the Camp BASIC web site.
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I authorize Camp BASIC to release the following information to other volunteers, staff and campers who have also attended Camp BASIC: (*)
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Camper's Name for Photo and PR Release:
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Parent's or Guardian's Name, for Camper Photo PR Release:
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Date you agreed to our Photo PR Release: (*)
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(today's date)
Authorization For Treatment
Authorization for the treatment of (Camper's Name): (*)
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Treatment Authorization Agreement: (*)
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Name of Parent or Guardian (*)
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Date of Authorization for Treatment (*)
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(today's date)
Permission To Attend Camp BASIC
Please check the box to grant your permission: (*)
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Camper's Name: (*)
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Parent or Guardian of Camper who will participate: (*)
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Date when permission was given for Camper to participate: (*)
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(today's date)
Scholarship
Would you like to apply for a Scholarship?
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Please explain to us why you wish to apply for a Scholarship:
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$100 Deposit
After you click on the "Submit Registration Information" button, you will be directed to the PayPal web site where you will use a credit card, debit card, or PayPal account to send us your $100 deposit.
Are you a human?
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