Camp Registration

CAMP REGISTRATION

All information provided is confidential and will only be shared with the ESP Camp Leadership Staff.

Campers Name *

First

Last

Guardians Name *

First

Last

Emergency Contacts*YOU MUST LIST FIVE (5)

Emergency Contact Name 1: *

Relationship to Camper 1: *

Phone Number 1: *

Emergency Contact Name 2: *

Relationship to Camper 2: *

Phone Number 2: *

Emergency Contact Name 3: *

Relationship to Camper 3: *

Phone Number 3: *

Emergency Contact Name 4: *

Relationship to Camper 4: *

Phone Number 4: *

Emergency Contact Name 5: *

Relationship to Camper 5: *

Phone Number 5: *

Is there anyone who CANNOT pick up your camper? *

YES NO

If YES, who? *

Please read the following statements carefully then type your full name in the box. This will act as an electronic signature and you will be fully responsible for that signature.

I understand that the first time my camper endangers the safety of an ESP camper, staff member, visitor, etc., he/she will be removed from the program for one day and I will meet with the Camp Director to discuss his/her behavior. *

I understand that the second time my camper endangers the safety of an ESP camper, staff member, visitor, etc., he/she will be removed from camp for no less than one week and possibly the entire summer and I will meet with the Camp Director to discuss his/her behavior. *

I understand I may request a meeting with the Camp Director, and other ESP staff, at any time to discuss my camper. *

Waiver of Liability: I, as a parent or guardian of the camper named above, do hereby give my permission for the camper to attend and participate in all activities at Extra Special People, Inc. summer camp. To the extent permitted by law, I agree not to hold ESP, the camp employees and volunteers, and all individuals associated with the program liable for any injury or harm to my child as a result of my child’s participation in camp activities or while my child is in transit to or from the program and activities. I also give permission for the contact persons listed above to pick up my child in an emergency if I am unable to do so. *

Our older campers sell drinks at the camp canteen every day to enhance money and social skills. All money from drink sales will go to projects for the campers. We accept all caffeine free drinks (diet and regular) such as: Sprite, 7up, Caffeine-free Coca-Cola, bottled water.

Will you donate drinks to our canteen? *

YES! Thank you – Please bring drinks to Mandatory Registration on May 1, 2011. NO

IT’S ALL ABOUT THE CAMPER!

All information provided is confidential and will only be shared with the ESP Camp Leadership Staff.

Child’s Strengths (Please list at least 5): *

Child’s Diagnosed Disability/Disabilities: *

Goals you would like for your camper to obtain or maintain during summer camp (Please be specific and consult teacher): *

Child’s swimming abilities/pool needs: *

What special eating habits/allergies does your child have? What are their favorite foods? *

Your (parent/guardian) biggest concern/worry when sending your camper to camp: *

OTHER INFORMATION

All information provided is confidential and will only be shared with the ESP Camp Leadership Staff.

WALKS *

EATS: *

USES TOILET *

SWIMS *

BOWLS: *

Manual Wheelchair *

Electric Wheelchair *

Walker *

Crutches *

Seizures *

Catheterization *

Feeding Tube *

Breathing Treatment *

Diabetes *

Shunt *

Glasses *

Hearing Aid(s) *

AFOs or Other Braces *