CAMP - Initial Application Gravity Form

ADEC's Summer Camp 2023 - Mon. June 5th - Fri. Aug. 4th | 9AM - 3PM

All campers are expected to have transportation to and from camp, and to bring their own lunches each day.

Limited sign-ups are available. Applications will remain open until April 28th or until all spots are filled.
Camper's Information
Name*
First Last
CAMPER'S Date of Birth:*
Gender*
- Male
- Female
Address*
Street Address City State ZIP Code
T-Shirt Size*
Is your camper on the Medicaid waiver?*
- Yes
- No
Case Manager*
Case Manager Information*

Please provide a phone number and email.
I understand that without Medicaid funding, I will need to discuss payment options and sign a contract with ADEC.*
- Yes
- No

Medical Information
What is your camper's diagnosis?*
Allergies*
Please list any allergies to food, medication, animal/seasonal triggers and any other allergies.
Does your child have an EpiPen?*
If your child does have an EpiPen, describe the allergy requiring its use.
Does your child have seizures?*
List the frequency, type, and potential triggers for their seizures if applicable.
Does your camper take any medication? If yes, please list the name, dosage and reason below:*
Will any medication need to be given during ADEC Summer Camp hours? If yes, which medicine and when?*
Additional Information
Please give any other information that would be helpful for staff to know about your camper.*
Does your child wander off (elopement)?*
Has your camper participated in ADEC's Summer Camp in the past?*
- Yes
- No
Does your camper receive other services provided by ADEC?*

If yes, please list.

Enrollment Agreement Terms | I understand that I am enrolling my camper in ADEC Summer Camp. My camper will be attending Monday through Friday each week at ADEC Summer Camp. 1) I will keep the Program Coordinator informed of any changes to my camper's information. 2) If a medical emergency arises, I give Program staff permission to treat and care for my camper. I understand that the staff will first attempt to contact me. If I am not readily available, I give Program staff permission to contact Emergency Personnel if immediate hospital attention is needed. 3) I agree to adhere to the state policies and procedures of ADEC Summer Camp, and give my camper permission to participate in this program.*
By typing your name in the box below, you have read and agree to the Enrollment Agreement Terms stated above.
Date Signed*
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ADEC's Summer Camp 2023 - Mon. June 5th - Fri. Aug. 4th | 9AM - 3PM