-Applicant must be able to communicate verbally, by sign language or through use of a communications board

-Applicant must complete and return with this application one copy of the enclosed medical review, completed by the parents/guardian. In addition, a second copy of the enclosed medical review must be SIGNED BY HIS OR HER TREATING PHYSICIAN, and submitted within six weeks prior to camp session.

Insurance:  Apple Dumplin’ Camp does not provide health and accident insurance for campers. Campers must carry their own insurance or be prepared to pay the cost of any medical services while at camp.

Sessions:

Sessions run from Drop off on Monday (between 1 p.m. and 4 p.m.) until Saturday at 2 p.m. The closing ceremony begins at 1:00 on Saturday. The ceremony is mandatory for all campers and we strongly encourage parents/guardians to attend.

Activities:

Trail rides, hayrides, roundups, wilderness study and craft, hiking, fishing, drama, nightly Western theme activities, arts and crafts, chapel AND MORE! (subject to availability)

Transportation:

Must be arranged and accommodated by individual campers. Please contact us if transportation is a problem.

Costs:

There is no charge for attendance at Apple Dumplin’ Camp!  It cost approximately $210 for each individual to attend Apple Dumplin’ Camp for one week. The total cost for the camping experience is provided by Arise and Walk Ministries of New Mexico, Inc., with support from donations from the general public and business community. CONTRIBUTIONS ARE GREATLY NEEDED AND APPRECIATED TO ENSURE THE ONGOING OPERATION OF APPLE DUMPLIN’ CAMP. This is your camp so PLEASE PASS THE WORD!

ALL QUESTIONS MUST BE ANSWERED. Please print legibly.

Applicants name:_________________________________________________Gender:____________________

Height:______________ Weight:_____________ Date of Birth:_________________

Primary Disability______________________________________________________

Secondary Disability:___________________________________________________

If mentally Challenged, give functioning age:_____________

{previous illness, conditions, or characteristics (check all that apply).

___Cough Diphtheria ___Asthma ___Rheumatic Fever ___Emotional Disorders

___Diabetes Sleepwalking ___Bedwetting ___Psychological Disorders

___Hyperactivity ___Chicken Pox ___epilepsy ___Autism

___ ________________ ___ ________________ ___ __________________

Any recent, serious medical illness or surgery? ______________________________________________

____________________________________________________________________________________

Are immunizations current? Yes No (please provide a copy of immunization record)

Allergies (including medications and food):________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________

LIST ALL PRESCRIBED MEDICATIONS:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Hearing: Right ear__________db Left ear__________db

Vision: Totally Blind:______

Legally Blind:______(20/200) or side vision not more than 20 with correction.

Low Vision:______vision or 20/40 or less with correction.

Uncorrected:______L/R______ Corrected:______L/R______

Neuromuscular:

1) Paralysis or loss of muscle function in:

a)Upper Extremities:_____________________________________________________________

b)Lower Extremities:_____________________________________________________________

c)Trunk:_______________________________________________________________________

2)Convulsive or neuro-motor seizures:______________________________________________________

a)Type:________________________________________________________________________

b)Frequency:____________________________________________________________________

c)Duration______________________________________________________________________

d)Last Occurrence:________________________________________________________________

Other Evidence of Pathology:

1)Cardiovascular:________________________________________________________________________

2)Pulmonary:___________________________________________________________________________

3)Other:_______________________________________________________________________________

Activity level advised? ____Non-strenuous (please explain)

____Minimum

____Moderate

____Full

I approve camping activities, including participation in arts and crafts, recreation and games, overnight campouts, and supervised swimming.

Physician’s name:___________________________________ Signature:________________________________________________

Street Address______________________________________ City, State, Zip:___________________________________________

Day Phone:________________________________________ Emergency Phone:_________________________________________

Apple Dumplin’ Camp Accommodation Information:

St. Address:_____________________________________

City, State, Zip:___________________________________

Phone:__(______)_________-______________________

Primary Disability:________________________________________________________________________

Secondary Disability______________________________________________________________________

If mentally challenged give functional age:______________________

School:___________________________________Program:__________________________________

Residential:________________________________Program:__________________________________

Circle the ones that apply: A=Always, S=Sometimes, N=Never.

Electric Wheelchair A S N Hearing Aids A S N

Wheelchair A S N Glasses A S N

Braces A S N Cane A S N

Walker A S N Guide Dog A S N

Crutches A S N Helmet A S N

Comm. Board A S N Sign Language A S N

Other:________________ A S N Other:___________ A S N

Circle the one that applies: I=Independent, A=Assistance, TC=Total Care.

Dressing I A TC

Comments:_________________________________________________________________________

Feeding: I A TC

Dietary Restrictions/comments:_____________________________________________________________

_______________________________________________________________________________

Toiling:

Diapers: I A TC

Catheter: I A TC

Manual Assistance I A TC

Medical Assistance I A TC Bedwetting YES NO

Comments:_________________________________________________________________________

_________________________________________________________________________________

Bathing: I A TC

Brushing Teeth: I A TC

Brushing Hair: I A TC

Shaving I A TC

____________________________________________________________________________________________

Have you attended Apple Dumplin’ Camp before? Yes No If so, when?________________________

Have you been away from home before? Yes No

Have you ever attended a camp before? Yes No If so, where and when? ______________ _______________________________________________________________________________

Problematic Behavior:_____________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________

*IF CAMPER IS NOT THEIR OWN GUARDIAN PLEASE SUBMIT A COPY OF GUARDIANSHIP AND HAVE BOTH GUARDIANS SIGN BELOW.

As a condition of participation and in order to provide a safe environment for all campers, Apple Dumplin’ Camp adopts a policy of reasonable searches and seizures of the person and of personal property in situations of suspected theft, illegal drugs, or possession of contraband items such as weapons, fireworks, and alcohol. Your signature on the enclosed application will be deemed as a written consent to such reasonable searches and seizures and a waiver of all claims against Apple Dumplin’ Camp for conducting the same.

x_______________________________________ x_______________________________________

Dated this______________day of _________________, 19_____.

Signature of Applicant___________________________ Witness to signature________________________

EMERGENCY INFORMATION

I hereby authorize a)physician's, nurses, hospitals and their authorized personnel employed, contracted or paid on a fee basis by the camp to perform all the treatments and procedures deemed necessary; and

b)the release of medical/hospital records to the camp from existing medical/hospital records; and

c( the release of medical/hospital records possessed by the camp to physicians, nurses, hospitals and their authorized personnel for the performance of treatment and procedures as deemed necessary upon

(camper’s name)______________________________________________________________

Date:_________________________

Signature of Guardians: x_______________________________ x_________________________________

Insurance Information:

Company Name:______________________________________________________

Contact Person:_______________________________________________________

Policy number:_______________________________________________________

Billing Address:______________________________________________________

______________________________________________________

Emergency numbers:

1)Name:_____________________________Relation to  Camper_________________________

Day Phone:( )___________-__________________Evening Phone:( )___________-____________

2)Name:____________________________Relation to Camper_________________________

Day Phone:( )___________-__________________Evening Phone:( )___________-____________

Vacationing Information:

Location of Guardian:_______________________________________________________________________

Hotel Name_____________________________________________________________________________

Hotel Number:( )_________-________________ Pager Number ( )________-_______________