RCM Camper Questionnaire

Camper Questionnaire

Please complete the form below.

Required Fields *

Camper Name *

Camper Birth Date (mmddyyyy) *

Camper Mailing Address *

Contact Name *

Contact Phone Number

Contact Email *

Week of Camp registered for * Adult II is currently full. You can apply for a different week or be placed on thte waiting list.

What is the camper’s diagnosed disability/disabilities? *

Camper’s Personal Health Care number *

Emergency Contacts

Please provide 2 emergency contacts for the camper.

**Both emergency contacts MUST be available to pick up the camper at any time throughout the week in case of early dismissal, for any reason as determined by Directors and/or Manager.

A copy of the camper’s MAR (medication administration record) MUST be provided to camp at time of camper drop off or before. You can request this directly from your pharmacy.

Primary Emergency Contact Name & Relationship to Camper *

Primary Emergency Contact Phone Number *

Secondary Emergency Contact Name & Relationship to Camper *

Secondary Emergency Contact Phone *

Camper’s physician name *

Camper’s physician phone *

Pharmacy Name * Please provide a copy of the camper’s current MAR at time of drop off.

Pharmacy Address *

Pharmacy Contact Number *

Pharmacy After-Hours Contact Number Pharmacies have a pharmacist on-call for emergency situations, you may need to check with your pharmacy for this number.

Medical Information

Please complete the fields below. If this is the Camper’s first year at camp, a medical form completed by a doctor may be requested by the Camp Manager.

Daily Living Skills

Regarding the registered camper, what level of assistance is required for the following tasks...

Communication

Please note that any communication aids need to be sent with the camper.

What method(s) of communication does the camper use to communicate? *

Verbal Written Gestures Sign Language Word board/book (PECS) Other

If other, please state here

If the camper uses sign language on a limited basis, please state what signs are commonly used

Is the camper able to read? *

Yes No

If yes, how well? (Approx. grade level)

Additional comments regarding communication

Mobility

Please note that any aids must be sent with the camper.

Toileting

If the camper utilizes incontinence products, please send with the camper.

Please specify if the camper is incontinent *

No concerns (full bladder & bowel control) Partial (occasional accidents) Incontinent (at all times) Incontinent (at night only) Other

If other, please state here

Additional comments regarding toileting

Dietary

Please note that depending on the dietary requirements, the camper may be requested to bring their own food or supplements.

Does the camper have any food allergies or restrictions? (peanuts, gluten free, etc.) *

Yes No

If yes, please list the allergy and/or restriction below with camper’s reaction if exposed

If dietary requirements listed above, how they managed? (medications, avoidance, etc.)

Does the camper require softened/blended meals? *

No Soft foods only Blended meals (no solid food) Other

If other, please state here

Additional comments regarding dietary needs

Behavioral

Please note that if a behavioral support plan (a document that describes behavior of concern along with signs of anxiety and how to address the concerning behaviors) is in place for the camper, a copy MUST be provided to camp.

Please describe how you know the camper is happy? (states they are happy, smiling, high pitched vocalizations, etc.) *

Please list any fears the camper may have that camp should be aware of? (thunderstorms, water, heights, etc.) *

Please describe how you know the camper is upset? (states they are unhappy, crying, focuses on one person/object, walks away, hides, etc.) *

How can camp support them through any upsetting moments, fears or uncertainties? (singing songs, going for a walk, listening to music, etc.) *

Additional information regarding the camper’s behavior: *

Does the camper have a behavioral support plan? *

Yes No Unsure

Does the camper utilize sensory items? * For example: fidgets, pop-its, weighted blankets, headphones with music, etc.

Yes No

If yes, please list some of the items the camper prefers:

General Information

What activities does the camper enjoy? *

What activities do not interest the camper? *

Please list any limitations for the camper, not stated above, that camp needs to be aware of *

Please provide any additional information you believe camp should be aware of to ensure a safe, fun and successful week for the camper: *

Name & relationship to camper of person(s) completing this questionnaire: *

I and/or the camper, would like to join the email distribution list for Rehoboth Camp. * Emails are sent periodically throughout the year and you can unsubscribe at any time.

Yes No

If yes, please enter email for mailing list.

I attest that the information provided here is true, to the best of my knowledge and understanding. *

Yes