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I slept and dreamt that life was a joy. I awoke and saw life was service. I acted and behold service is joy. Rabindranath Tagore

Camp Able Application & Scholarship Request Form

Camp Able Camper Application

Campers please submit your applications starting January 14, 2013.  All applications will be acknowledged immediately.

This application must be completed by a parent or legal guardian.  Please answer each question as fully and honestly as you can.  If you have any questions or require assistance, please contact The Rev. Kyle Bennett at St. Mark's Episcopal Church, Marco Island at 239.394.7242.

Each camper is required to have had a physical examination within the past 12 months. The camper’s primary care physician is required to sign a form to that effect and provide the date of the camper’s last check-up.
Date
*Camper's First Name
*Camper's Last Name:
Camper's Sex
 Male  Female  
Camper's Age
Camper's Height
Camper's Weight
Grade Completed
*Camper's T-shirt Size
 Youth Medium  Youth Large  Small  Medium  Large  XLarge  XXLarge  XXXLarge  
Camper's Address
Camper's Address2
Camper's City
Camper's State
Camper's Zip Code
Camper's Date of Birth

The following section requires information for the Parent or Guardian (PG), as well as emergency contact and alternate authorization.
*PG First Name
*PG Last Name
*PG Email
PG Address
PG Address2
PG City
PG State
Zip Code
*Home Phone (999.999.9999)
Business Phone
Cell Phone
Church and Church Location:
Emergency Contact Name
Emergency Contact Phone.
Emergency Work Phone
Emergency Cell Phone
Authorized Participant Pick-up Name & Phone
How did you hear about Camp Able?

Camper Profile

The following information is helpful in allowing us to get to know your child and  to assess the special needs your camper may require. Please be as descriptive as possible. Thank you.
What are his/her special interests?
What would he/she like to do at Camp Able?
How would you describe his/her disability
What would you like your camper to gain by going to Camp Able?
If camper requires assistance eating, please describe specifically
Does he/she use a wheelchair?
 Yes  No  
If camper requires assistance bathing, dressing or with personal hygiene, please describe specifically
If camper has difficulty communicating, please describe specifically
If camper can NOT eat a normal camp diet, please describe their special diet requirements
If camper has allergies, please list the allergy(s) and treatment(s)
If camper has any medical problems, please list the problem(s) and treatment(s) and/or precautions required
If your camper is subject to seizures, please specify treatment and/or control medications
Describe any sleeping issues and what needs to be done if your camper wakes in the night
If your camper has any other difficulty, e.g.. hearing, seeing, etc, please describe the difficulty and assistance needed
Is there anything else you are concerned about or information the Camp Staff should know about?
Other, please detail
*I give permission for the use of pictures and videos of my camper for the promotion of Camp Able.
  Yes
 No

Camp Able Application

Thank you for your honest and comprehensive responses. It is our hope that the rewards will be well worth the effort. If you are not requesting scholarship assistance, please advance to and click on "Submit" below to enter your Application for consideration.

Camp Able Scholarship Request

Please note that funds are limited and that scholarships will only be awarded in situations of financial hardship, with the understanding that without these monies the participant would not be able to attend the event.
The cost of the camp is $350.00.  The maximum scholarship that will be awarded is $250.00. The remaining balance due of $100.00 will be required immediately after the camper is accepted and you have received written confirmation. Do not send any payments before receiving confirmation of acceptance.
Please enter the reason your camper requires financial assistance

This section requires information from your camper's Primary Care Physician, as well as insurance and medical information.

Please enter the information requested, then click here to print out the form required for the Doctor's Signiture.
(Camp Able requires that each camper have a physical examination within the past 12 months)
Doctor's Name
Doctor's Address
Doctor's Phone
Number of years as this Doctor's patient
Date of camper's last check-up
Date of camper's last tetanus shot
Operations or Serious Injuries & Dates
Childhood Diseases - Dates
Immunizations--please check appropriate boxes
 DTP Series  Booster01  Booster02  
Do you have Medical Insurance for your camper?
 Yes  No  
Name of Insurance Company
Insurance Company Phone
Insurance Address
Insurance Policy Holder's Name
Insurance Policy Number
Date of Insurance Policy

Medications

Please list each medication your child will bring to Camp Able and provide directions for administering the medication.

All prescribed medication and over-the-counter medications must be in the original container with the correct name, date, instructions and physician's name on the label. These must be handed in to the licensed health professional who will be on duty for the duration of Camp Able and who will be responsible for the dispensing of all medications.

Name of Medication 01
Dosage
Times
Name of Medication 02
Dosage
Times
Name of Medication 03
Dosage
Times
Name of Medication 04
Dosage
Times
Name of Medication 05
Dosage
Times
If this application is not accepted, please be certain you have completed ALL required fields.

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move


 
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