How to Sign Up Your Camper
at Camp Grace Bentley
Camp Dates for 2010 are:
Session 1 Sunday, June 27- Monday July 5
Session 2 Thursday, July 8 to Friday, July 16
Session 3 Monday, July 19 to Tuesday, July 27
Session 4 Friday, July 30 to Saturday, August 7
Campers may attend a maximum of two sessions with one session break in between.
Please check if you would like to attend both sessions.
We are unable to grant requests for late arrival or early pick-up times. Please choose a session where your child can be in attendance at camp for the entire nine days
.
I would like my child to attend session(s): Please indicate 1st(1) and 2nd(2) choices:
Session 1 Sunday, June 27- Monday July 5
Session 2 Thursday, July 8 to Friday, July 16
Session 3 Monday, July 19 to Tuesday, July 27
Session 4 Friday July 30 to Saturday, August 7
**Applications must be submitted no later than 3 weeks before session begins.
**
Email Address
Camper’s Name:
First
Middle
Last
NickName:
Address:
Home Phone
Cell/Work Phone
Email Address
Gender
Select One
Female
Male
Date of Birth
Age at Time of Camp
Camper Diagnosis
Can Camper Function on a 3-1 camper/counselor ratio?
Please Select
Yes
No
**** Please note that we are not equipped to accept children who require one-on-one care. ****
Parent or Guardian’s Full Name:
Address (if different than above:
Emergency Phone Numbers:
(REQUIRED!)
Parent/Guardian Name:
Home Phone:
Cell Phone
Work Phone:
Parent
/Guardian
Name:
Home Phone:
Cell Phone
Work Phone:
If parent/guardian cannot be reached, whom shall we contact, in order of preference?
Name
Relationship to Camper
Phone
Name
Relationship to Camper
Phone
Name
Relationship to Camper
Phone
While the child is at Camp Grace Bentley, parents will be:
At Home
On Vacation and may be reached at:
Phone Number and Location:
Specific Dates Gone:
Adults to whom camper can be released:
Anyone to whom camper MAY NOT be released:
How did you hear about Camp Grace Bentley?
Disability:
(please check)
Cerebral Palsy
Epilepsy
Trainable Mentally Impaired
Muscular Dystrophy
Down Syndrome
Autistic
Spina Bifada
Emotionally Impaired
Other
Please describe the level of impairment
Please indicate the following (associated problem)
Normal
Impaired
Limitations
Hearing Ability
Vision Ability
Memory
Time Concept
Perceptual Ability -- Communications:
No Difficulty
Verbalizes, but may be difficult to understand
Non Verbal
Yes/No Responses Only
Please Explain
General Health:
Does child have seizures?
Please Select
Yes
No
If so, how long do they last?
Any respiratory difficulties?
Please Select
Yes
No
Does child fatigue easily?
Please Select
Yes
No
If so, symptoms to look for:
Medications:
All medications must be in the original container with the child’s name and dosage amount. We can not deviate from these directions.
Please send the exact amount of medication needed for the entire session.
Medication
Dosage
Time taken
Medication
Dosage
Time taken
Medication
Dosage
Time taken
Medication
Dosage
Time taken
Allergies to medication, please list:
Nutrition/diet notes, including allergies to food:
Proof of current immunizations must be presented:
DPT
MMR
Polio
Others
Has child had previous surgery?
Please Select
Yes
No
If so, date?
Broken Bones?
Please Select
Yes
No
Which Ones?
Precautions
Skin care:
Any open areas?
Please Select
Yes
No
Location?
Care notes
Special Equipment:
(Check those that apply)
Ambulation:
Eating:
Bracing:
Other:
Crutches
Special Cup
Short leg
Hoyer Lift
Cane
Straw
Long leg
Toilet / Commode
Walker
Special Dish
AFO (Plastic)
Shower Chair
Wheelchair
Special Utensils
Body Jacket
Shunt
Electric Wheelchair
Other
Hand Splint
Other
Amigo
Other
Other
Activities of Daily Living:
(please check all that apply)
Independent
Partial Resistance
Needs Full Care
Eating
Ambulation
Dressing
Bathroom
Bowel & Bladder
Personal Care Information:
Child’s approximate weight
Transfers: (please check)
Can make transfers independently
Can bear weight for pivoting
Must be lifted, cannot bear weight
Check any area where child may need assistance:
Showering
Shaving
Brushing teeth
Personal care during menstrual cycle
Other
Adjustment to Camp:
Has your child been to camp?
Please Select
Yes
No
If so, did he/she adjust well?
Please Select
Yes
No
Has your child ever been away from home before?
Please Select
Yes
No
Do you think he/she is likely to be homesick?
Please Select
Yes
No
Does your child have a history of emotional or behavioral problems? Please be specific:
How do you manage this behavior at home?
Please describe your child’s ability to follow directions:
Please describe your child’s ability to get along and interact with others:
Does your child sleep through the night?
Please describe any eating concerns:
Other information you would like to share about your child
The above information is true and accurate to the best of my knowledge.
I understand that Camp Grace Bentley is not equipped to service children who require one-on-one care or are unable to function on a 3-1 camper/counselor ratio.
Upon submitting application to Camp Grace Bentley please note:
Application to Camp Grace Bentley does not insure that your child will be accepted. A committee will review the application to determine if Camp Grace Bentley is equipped to accommodate the needs of your child. Many factors are taken into consideration.
The decision of the committee is final.
After submission of the online application you will be asked to download two additional forms which must be signed and mailed to:
Camp Grace Bentley
c/o Nancy Perri
1877 Maryland
Birmingham, MI 48009
Camper Physical Record which must be signed by a licensed physician
Release agreement which must be signed by the parent or guardian.
These forms are available to download after you click submit.
© 2010 The Michigan League for Crippled Children
