Camper Application Camper Application Step 1 of 2 50% Participant InformationLegal Full Name* First Last NicknameAge*Date of Birth* Gender*MaleFemaleHeight*FeetInches Weight*In PoundsPrimary language*Parent/ Guardian/ Caregiver InformationName* First Last Relationship*Home Phone*Cell Phone*Email* Address* Street Address City State ZIP / Postal Code Other Participant InformationDiagnosis - Primary*Diagnosis - SecondaryDetails*Date of Onset* Have there been any seizures in the last year?*YesNoDate of most recent* Type of seizure*Are they controlled?*YesNoEmergency Contact InformationEmercency Contact #1Name* First Last Home Phone*Cell Phone*Relationship*Emercency Contact #2Name* First Last Home Phone*Cell Phone*Relationship*Physician Name* First Last Physician's Phone Number*Hospital Preference*YesNoWhich hospital?*AllergiesDoes the participant have any allergies?*YesNoList all known Allergies & Reactions*Please include food, environmental, and medication allergiesAllergyReaction Past ParticipationHas this child participated in Camp River Run camps in the past?*YesNoAre any of the participants' siblings attending day camp?*YesNoPlease list the names of siblings attending* Medication InformationIs the participant currently taking any medications?*YesNoMedications*Please list all medications the participant is currently takingMedicationRoute: (oral, injection, etc.)DosageTime GivenPurpose Will the participant be taking medications during the day camp?*YesNoDietary RequirementsDoes the participant have any dietary restrictions?*YesNoList any food restrictions or special dietary needs.*Surgical HistoryHas the participant had any past surgeries?*YesNoList Past Surgeries*Personal CareDoes the participant require any personal assistance?*YesNoDressing*IndependentPartial AssistTotal AssistEating*IndependentPartial AssistTotal AssistToileting*IndependentPartial AssistTotal AssistBladder Control*NormalOccassionalIncontinentBowel Control*NormalOccassionalIncontinentBladder/Bowel OtherDescribeCommentsPhysical ConcernsDo you have any physical concerns?*YesNoRuns unassisted*YesNoWalks unassisted*YesNoBears weight on legs*YesNoBears weight on hands*YesNoUses hands independently*YesNoClimbs stairs*YesNoPrimary means of mobilityPower WheelchairCanWalkerManuel WheelchairBraces/Assistive devicesIf yes, Location*Transfers*No AssistPartial AssistTotal AssistEndurance*AverageFairPoorHand/eye coordination*AverageFairPoorCommentsSensory ConcernsDo you have any sensory concerns?*YesNoVision* Glasses Contacts Partially sighted/legally blind Totally blind Auditory*Partial Hearing LossTotal Hearing LossAssistive technology usedPlease, provide any information that may better assist us in meeting the sensory needs of your childBehavioralDo you have any behavioural concerns?*YesNoPlease explain any behavioral issues your child may exhibit or has exhibited in the past*Shows violence?*YesNoIf yes, please explain*Please, provide Successful Intervention Strategies used*(behavioral, rewards, consequences, etc.)Please download and sign the following document. Download You can scan the signature and upload it to the field below, or just bring it to your meeting.NameThis field is for validation purposes and should be left unchanged.