Camp Elevate Application

Camper General Information

Applicants Name*

First Middle Last

Preferred Name*

First

for Name Tag

Address*

Street Address City State ZIP Code

Primary Phone*

Work Phone

Cell Phone

Email*

Enter Email Confirm Email

Please enter a unique email for each family member to avoid creating duplicates in our system.

Emergency Contact Information

Emergency Contact #1*

First Last

Relationship #1*

Emergency Contact Phone #1*

Emergency Contact #2*

First Last

Relationship #2*

Emergency Contact Phone #2*

Emergency Contact #3*

First Last

Relationship #3*

Emergency Contact Phone #3*

Date of Birth*

applicant must be over 16

Gender*

Male

Female

Age*

By filling out this form you will be automatically added to our communications. If you wish not to receive please state below:

To assist us in ordering please indicate your desired T-shirt Size:*

What are your favorite activities?*

Please describe in detail challenging behaviors you may struggle with?*

What usually triggers challenging behaviors?*

What are effective responses to challenging behaviors?*

What are two or three effective rewards/reinforcements?*

Camper Abilities

Do you have a disability?*

Yes

No

If yes, please explain your disability

How do you communicate best? (verbally, sign language, liberator, Ipad, other)*

Do you use a wheelchair?*

Yes

No

Type of wheelchair?

If yes, Width of Chair:

Do you require any adaptive equipment?*

Yes

No

If yes, please list:*

List any physical and/or mobility limitations:*

General Authorization

PLEASE READ CAREFULLY, AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.  I affirm that I have legal custody of the minor children/persons indicated below. Should an emergency occur during the duration of BREAKAWAY, I give my authorization and consent for the BREAKAWAY staff to authorize necessary medical care for this child. Such medical treatment shall be provided upon the advice of and supervision by any physician, surgeon, or other medical practitioner licensed to practice in the United States.  I give my consent that information on this application may be communicated to BREAKAWAY staff and Crew Members for the purpose of being equipped to provide the best care and assistance possible to my family.  Permission is given only to Lift Disability Network to use photographs (individual or group) and/or multi-media images and recordings in the best interest of Lift Disability Network. I understand that photographs/video/images I take at any BREAKAWAY/Lift Disability Network function are for my personal use only. Personal internet use of any video/media should be approached with caution with regard to misrepresentation.  I release Lift Disability Network, its staff, and Crew Members, and the BREAKAWAY facility from all actions, damages, or personal injuries which may occur to me or a member of my family. I understand in the event of a minor injury I, or a member of my family, may receive first aid treatment. I will be informed as soon as possible of any injury or condition of one of my family members and will be responsible thereafter for their care. In the event of an emergency, injury, or illness, emergency medical services and I will decide the best course of action. If the BREAKAWAY staff is unable to reach me, I authorize them to take whatever action is necessary for the safety and health of my family members.  I understand that participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,  I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,  I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.  I realize that tobacco, alcohol, and illegal drugs are NOT ALLOWED.

Signature*

Type Full Name

Captcha

CAMP ELEVATE

Looking for something to do while schools and activities are on summer break? Club Elevate is hosting a one-week summer day camp for teens and adults with developmental disabilities. June 5-9, Mon-Fri 9am- 2 pm.

Come join the fun as we have a Disney-themed week of group indoor and outdoor games, music, art, baking, and more! Camp Elevate is limited to 30 spots, (10 teens and 20 adults) ages 16 and up, so register today.

Total cost for this amazing week??? $250.00