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574-848-7451
|
info@adecinc.com | Serving Elkhart and St. Joseph counties in Indiana
NEWS
DONATE
PROGRAMS
THERAPIES
SUMMER CAMP
DAY SERVICES
GUARDIANSHIP
TRANSPORTATION
RESIDENTIAL
SKILLS TRAINING AT THE HUB
WORK FOR ADEC
APPLY NOW
JOB INFO
ADEC INDUSTRIES
COMMUNITY
ART BY ADEC
SELF-ADVOCATES PODCAST
SILVER BULLETS
GAINING GROUNDS COFFEE SHOP
CONFERENCE CENTER
SILVER LININGS TRASH BAGS
HIRE AN ADEC CLIENT
GET INVOLVED
CONTACT US
NEWSLETTER
VOLUNTEER
EVENTS CALENDAR
RESOURCES
LEADERSHIP TEAM
ANNUAL REPORT
STRATEGIC PLAN
RESOURCES FOR PARENTS AND GUARDIANS
HISTORY
ADEC YOUTUBE
REPORT ABUSE OR NEGLECT
Search for:
NEWS
DONATE
PROGRAMS
THERAPIES
SUMMER CAMP
DAY SERVICES
GUARDIANSHIP
TRANSPORTATION
RESIDENTIAL
SKILLS TRAINING AT THE HUB
WORK FOR ADEC
APPLY NOW
JOB INFO
ADEC INDUSTRIES
COMMUNITY
ART BY ADEC
SELF-ADVOCATES PODCAST
SILVER BULLETS
GAINING GROUNDS COFFEE SHOP
CONFERENCE CENTER
SILVER LININGS TRASH BAGS
HIRE AN ADEC CLIENT
GET INVOLVED
CONTACT US
NEWSLETTER
VOLUNTEER
EVENTS CALENDAR
RESOURCES
LEADERSHIP TEAM
ANNUAL REPORT
STRATEGIC PLAN
RESOURCES FOR PARENTS AND GUARDIANS
HISTORY
ADEC YOUTUBE
REPORT ABUSE OR NEGLECT
Search for:
NEWS
DONATE
PROGRAMS
THERAPIES
SUMMER CAMP
DAY SERVICES
GUARDIANSHIP
TRANSPORTATION
RESIDENTIAL
SKILLS TRAINING AT THE HUB
WORK FOR ADEC
APPLY NOW
JOB INFO
ADEC INDUSTRIES
COMMUNITY
ART BY ADEC
SELF-ADVOCATES PODCAST
SILVER BULLETS
GAINING GROUNDS COFFEE SHOP
CONFERENCE CENTER
SILVER LININGS TRASH BAGS
HIRE AN ADEC CLIENT
GET INVOLVED
CONTACT US
NEWSLETTER
VOLUNTEER
EVENTS CALENDAR
RESOURCES
LEADERSHIP TEAM
ANNUAL REPORT
STRATEGIC PLAN
RESOURCES FOR PARENTS AND GUARDIANS
HISTORY
ADEC YOUTUBE
REPORT ABUSE OR NEGLECT
CAMP – Initial Application Gravity Form
Miranda
2023-03-15T13:36:10-04:00
CAMP - Summer Camp Registration 2023
Step
1
of
5
20%
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:
*
Month
1
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2023
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Male
Female
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
T-Shirt Size
*
Choose One
YS
YM
YL
S
M
L
XL
2XL
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.
Parent/Guardian Information
Parent/Guardian 1 Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Relationship to Camper
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Enter Email
Confirm Email
Personal Phone
*
Parent/Guardian 2 Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Relationship to Camper
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Personal Phone
Emergency Contacts
Emergency Contact 1 Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Relationship to Camper
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Secondary Phone
*
Emergency Contact 2 Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Relationship to Camper
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
Secondary Phone
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
*
Month
1
2
3
4
5
6
7
8
9
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12
Day
1
2
3
4
5
6
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
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