Camper Information Form

Full Name of Camper:

Name of person completing the form:

Relationship to Camper:

Contact Information for Camper:                               Your Contact Information:

Home Phone:                                  Home Phone:
Work Phone:                                   Work Phone: 
Cell Phone:                                   Cell Phone:    
E-Mail Address                            E-Mail Address *Required
Sex:       Male          Female
Age:
Date of Birth:

Below are questions about the camper’s physical, medical, and social abilities. Please be as candid and objective as possible when providing this information.

What is the camper’s primary disability (e.g. intellectual disability, attention deficit disorder, autism spectrum, Down syndrome)?

At what grade level would you estimate the camper functions in terms of reading and writing?

Describe the camper’s physical and medical limitations

Please use this space to provide us with additional information about the camper

If the camper is still in school:
Name of School: Grade:

If the camper is working, please describe the camper’s job and his or her duties:

Use the scale below to rate the camper on the following (Choose a 1-5 rating with 1 being low and 5 being high): (Space provided is for you to add comments about your ratings at the end of this section)

Relationships with others (Choose a 1-5 rating with 1 being low and 5 being high):                                                                                                           

Ability to control own interests, impulses, and desires (Choose a 1-5 rating with 1 being low and 5 being high):

Level of awareness of own limitations (e.g., knows what he or she can or cannot do) (Choose a 1-5 rating with 1 being low and 5 being high):

Does the camper have difficulty transitioning from one activity to another? If yes, what techniques are helpful in making the transition? (Choose a 1-5 rating with 1 being low and 5 being high)

Use the scale below to rate the camper’s skills and abilities in the following areas:

Initiate conversations using the telephone

Converse on the telephone using more than monosyllables to answer questions

Dial a family member or friend’s telephone number (OR Dial 911 and knows when it is appropriate to dial it)

Check for traffic before crossing the street

Take or use public transportation (bus or metro) by himself / herself

Make own bed

Brush teeth

Shower by himself / herself

Keep clothes organized

Remember medicine schedule

Follow simple directions

Accept supervision from females

Accept supervision from males

Describe the camper’s special interests or talents

Describe the camper’s emotional stability. What triggers anger or intense feelings? What are effective techniques to manage the camper’s behavior?

May we share the camper’s email address and/or phone number with other campers who are interested in staying in contact?

E-Mail:                                  Yes         No
Phone number:                   Yes         No

Please email the completed form to campatlantic@cox.net or mail hard copy to:

Tom Ingoldsby
Camp Atlantic
P.O. Box 7273
McLean, Virginia 22106

Verification code:
Re-type verification code:
This is a security to check to ensure you are a human user.