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Family Camp Application

CAMPER INFORMATION
Which weekend(s) will you attend?(Required)
Name of Camper
Gender
Address
What is your preferred method of receiving notifications and paperwork?
This information is used for statistical purposes only.
How did you find out about Easterseals Wisconsin Family Camp?

MEDICAL INFORMATION
Drug, environment, or food.
Vegan, lactose intolerant, gluten free, etc.
Do you require any personal care assistance outside of what your family or caregiver can provide during the session?
Do you require any adaptive equipment that you are unable to bring to camp?
IF THERE IS AN EMERGENCY AT CAMP, PLEASE LIST WHO TO NOTIFY
Emergency Contact #1
Emergency Contact #2
MOBILITY AND SPECIAL APPLIANCES
Indicate ALL that apply to camper:
If camper uses a wheelchair, when/for how long?
FAMILY MEMBERS ATTENDING CAMP SESSION
Name of Family Member #1 ($50)
Address
MM slash DD slash YYYY
Gender
For statistical purposes only
Are you vaccinated against MMR?
Name of Family Member #2 ($50)
Address
MM slash DD slash YYYY
Gender
For statistical purposes only
Are you vaccinated against MMR?
Name of Family Member #3 ($50)
Address
MM slash DD slash YYYY
Gender
For statistical purposes only
Are you vaccinated against MMR?
Name of Family Member #4 ($50)
Please note: If you have additional family members who would like to attend, to please send an email to: eswcamps@eastersealswisconsin.com
Address
MM slash DD slash YYYY
Gender
For statistical purposes only
Are you vaccinated against MMR?
Immunization Records Release(Required)
Liability & Field Trip Release(Required)
Media Release (optional consent)
Photo Release (optional consent)
National Sex Offender Background Check(Required)
Application Confirmation(Required)
Please describe fears, likes, dislikes, or habits that you feel would be helpful for the staff to know. Please provide any suggestions, about you or your family members, you may have for a great weekend at camp.