Disability Information Form

This form needs to be filled out for ALL campers with special needs

Please complete the form below.

Camper Buddy(Required)

Please assign a buddy for my child

I will provide a buddy for my child

Buddy's Name

First Last

Camper's Information

Have you attended the Team Up Camp before?(Required)

New Camper

Returning Camper

Name(Required)

First Last

Age(Required)

Sex(Required)

Male

Female

Approximate Weight(Required)

Diagnosis(Required)

Parent's Name(Required)

First Last

Email(Required)

Phone(Required)

Best Time to Contact:(Required)

Circle the description that best fits your child’s physical abilities:(Required)

No physical challenges

Unsteady/poor balance

Uses a walker

Can help w/transfers

Total assistance

Physical Characteristics: Please check all that may apply at camp

Assist w/walking(Required)

Minimal

Moderate

Full

None

Assist w/transfers(Required)

Minimal

Moderate

Full

None

Assist w/Fine Motor Skills(Required)

Minimal

Moderate

Full

None

Assist sitting on ground(Required)

Minimal

Moderate

Full

None

Assist sitting at picnic table(Required)

Minimal

Moderate

Full

None

Aides(Required)

Walker

Stander

Non-ambulatory

Wheelchair/stroller/scooter

AFOs/Orthotics

Cane

Hand Splints

None

Please describe use of all checked aides and any additional aides, including time/situations used and expected involvement of Buddy.

Behavior Characteristics/Sensory Issues

Difficulty following directions(Required)

Yes

Impulsive(Required)

Yes

Short attention span(Required)

Yes

Is able to stay with a group(Required)

Yes

Unusual fears(Required)

Yes

What fears?

Sensitive to touch(Required)

Yes

Sensitive to noise(Required)

Yes

May become harmful to self(Required)

Yes

Can be violent towards others(Required)

Yes

List any other sensory issues:

Please describe sensory issues:

Please describe child’s behaviors and recommended response of Buddy for all checked items above.

Rewards/incentives/strategies that may be helpful:

Communication: Please check all that apply at camp.

How will your child communicate with his/her Buddy?

How will your child communicate with his/her Buddy?(Required)

English

Spanish

Sign Language

Gestures

PECS

Augmentative Communication Device

Non-Verbal

Other

Speech Delays(Required)

Minimal

Moderate

Full

None

Please describe use of all checked language supplements and/or delays as they would involve communication between your child and his/her Buddy at camp.

Dietary Considerations

Requires Assistance Eating?(Required)

Minimal

Moderate

Full

None

Please check all that apply at camp.(Required)

G-tube– Buddy/Nurse will feed

Pureed/Soft Foods

Parent will feed

Uses straw for liquids

Environmental considerations for feeding

Will bring lunch from home

Uses special cup/utensils

Special positioning for feeding

Nothing by mouth

Thickened liquids

None

Please describe all checked dietary considerations and others not listed. Include involvement of your child’s Buddy at camp.

Please describe any food allergies.

Toilet Routine

Requires assistance in toilet?(Required)

Minimal

Moderate

Full

None

Please check all that apply at camp.(Required)

Requires supervision in toilet

Diaper changes – Buddy/volunteer responsible

Diaper changes – Parent responsible

None

Please describe type of assistance required from Buddy/volunteer for all checked items and the child’s usual routine.

Respiratory Considerations

Please check all that apply at camp.(Required)

Breathing difficulties

Asthma - meds

Asthma - inhaler

Chronic pulmonary disease

None

Please describe all checked respiratory considerations and any others not listed. Include involvement with Buddy or other volunteers.

Allergies

Check all those that apply.(Required)

Bee Stings

Latex

Animals

Milk/Dairy Products

Food

Medication

Environmental

None

Please list any allergies that are severe or life threatening.

Seizures

Does your child have a history of seizures?(Required)

Yes

Medication: Will your child require a camp volunteer to administer medication while at camp?(Required)

If yes, a Medication Form will be mailed prior to camp for specific information on medications.

Yes

Other Medical Information including medications.

Consent for Buddy Request(Required)

As a parent/guardian that is requesting a buddy, I understand that all efforts will be made to find a buddy for my camper. If a volunteer that has the skills required to meet my child’s needs cannot be found, I understand that I may be asked to stay with my child at camp or my child may be asked to discontinue the camp experience.

Please read and sign the following disclaimer:

I understand that the buddy assigned will do their very best to care for and meet the individual needs of my child. Should my child’s behaviors or needs become a danger to themselves or others, I will be called to pick up my child from camp immediately. Parents and camp directors will discuss the situation and make a decision regarding the child’s return to camp.

Signature(Required)

Date

MM slash DD slash YYYY