Camper Application

Before completing this application, please read our eligibility requirements. If you have any questions, please email us at acd@lionscamphorizon.org.

Camper Information

Name

First *

Middle

Last *

Does your camper have a preferred name/nickname?

Date of Birth *

Gender *

Male

Female

Does Camper reside with Parent/Guardian? *

Yes

First and Last Name(s) for Parent/Guardian(s)

First Name for Parent/Guardian #1 *

Last Name for Parent/Guardian #1 *

Email Address *

Phone Number *

First Name for Parent/Guardian #2

Last Name for Parent/Guardian #2

Email Address

Phone Number

Parent/Guardian's Mailing Address

Street Address *

Address Line 2

City *

State / Province *

ZIP / Postal Code *

Has the camper attended Lions Camp Horizon previously: *

Yes

Has camper previously attended a different overnight/residential camp? *

Yes

Please select ALL session dates your camper is available to attend camp. We will prioritize your 1 st and 2 nd choice but may need to look at other date options if those are not available. Please note Adventure Camp is subject to eligibility requirements. First time campers must attend Base Camp. *

Adventure Camp 1 - July 6-10*

Base Camp 1 - July 13-17

Base Camp 2 - July 20-24

Adventure Camp 2 - August 3-7*

First Choice:

Second Choice:

How many sessions would you like your camper to attend? *

Note: Our goal is to provide as many individuals as possible the opportunity to attend a camp session. Space is limited but we will make every effort to fulfill your request for multiple sessions.

Registration Deposits:

A $50.00 non-refundable deposit is required of private-pay campers for each session requested. The deposit is not required of campers using DSHS/DDA funding. Campers using DSHS/DDA funding must have respite hours and payment pre-approved by their Case Manager before we will hold session dates. We will submit a pre-authorization request to DSHS/DDA but it is the Parent/Guardian’s responsibility to follow-up and ensure we receive it within 14 business days of the request.

Camp Session Payment Method: *

Private Pay

Respite Benefits – DSHS/DDA

Emergency Contact Information

If you will not be available via phone for questions regarding behaviors, illness, dietary restrictions, etc., or if you
will not be available to come pick up your camper due to illness, behaviors, or emergency, please provide the name and contact information for the person we should contact and/or release your camper to. This person will also be contacted if we have made multiple attempts to reach you, but are unable to get in touch.

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Cell Phone: *

Personal Information

It is crucial that the information provided below is accurate and as detailed as possible. This ensures your camper, and our staff, have everything they need for a safe and enjoyable camp experience. If there is anything we should know that isn't addressed in the following questions, please add notes or contact us at acd@lionscamphorizon.org

Activity Level

Activity level (select all that apply) *

Has typical attention span

Has short attention span

Easily distracted

Is hyperactive

Will participate in most activities

Refuses to participate/ prefers to watch

Is underactive (needs motivation)

Stays with group

Wanders from group or is a “runner”

What are some favorite activities? *

What are some LEAST favorite activities? *

Care Needs (select all that apply): *

Has good fine motor skills

Has poor fine motor skills

Needs hand over hand

Sensitive to loud noises

Sensitive to flashing/ twinkling lights or disco balls

Hygiene and personal care (select all that apply) *

Uses toilet independently

Uses a toilet on a schedule

Requires assistance using the toilet

Does not use toilet at all; uses incontinence briefs

Requires being woken at night to use the toilet

Showering (select all that apply) *

Can shower independently

Needs assistance adjusting water

Needs verbal cues during shower

Needs assistance shampooing

Needs assistance soaping

Needs shower chair or bench

Needs complete assistance in the shower

Prefers evening shower

Prefers morning shower

How frequently does your camper shower?

Please provide any additional details to help with personal hygiene and toileting.

Dressing (select all that apply) *

Has no difficulty dressing

Needs some assistance with dressing/undressing

Needs total assistance with dressing/undressing

Needs assistance choosing clothes

Needs assistance tying shoes

Needs assistance with buttons/snaps/zippers

Needs assistance with belt

Please note any other dressing needs we should be aware of.

Please provide usual bedtime and usual wake-up time: *

Please provide any schedule or other information that may be helpful with camper's night routine.

Please provide any other communication challenges, styles, and strategies that may be helpful.

Does your camper have a history of physical or verbal aggression? If so, please provide triggers/circumstances and re-direction/de-escalation techniques used to calm your camper. *

Has your camper been charged or convicted of a crime? *

Yes

We periodically have volunteer groups bring horses for riding, therapy animals or "guests' from a petting zoo. Please let us know:

Is your camper afraid of animals? What kind?

If your camper is allergic to any animals, please specify the type, reaction, and the severity.

Medical Information

(to be completed by parent or guardian, not physician)

These are general medical questions, a Health Examination Form will be provided for your camper's Doctor or Nurse Practitioner to complete.

Camper’s Primary Diagnosis: *

Secondary Diagnosis:

Chronic Medical Conditions:

Does your camper have seizures? *

Yes

Please list any other devices or equipment your camper has and what level of assistance is needed.

Effective January 2024, Camp Horizon requests all medications are pre-packaged in Bubble Packs or Simple Dose Packs if your pharmacy provides this service.

If your pharmacy does not provide this service, please ensure all medications are in the original pharmacy bottle. This must include the campers name, medication name and dosage instructions. Over the counter medications, supplements, ointments, etc., must be listed on the Health Exam Form completed by a physician. All medications and dosages must match the Health Exam Form.

Please list ALL current medications with DOSAGE & TIME medication is administered (Morning, Mid-Day, Evening, As Needed) *

Upload Medication Sheet (optional)

Dietary Restrictions:

Our kitchen staff must accommodate a wide range of medically required dietary restrictions and food allergies. We must distinguish between essential dietary restrictions and personal preference. We cannot accommodate personal preference. Please only list restrictions that are medically diagnosed/prescribed and not personal preference. The Health Exam Form must list these restrictions and/or allergies. We offer a variety of options at each meal for those with a limited selection of foods they will eat.

Please reach out to acd@lionscamphorizon.org with additional questions or concerns regarding dietary needs.

Has the applicant been diagnosed by a physician with a dietary condition such as Celiac Disease, PKU, Diabetes, food allergies, or any other condition? If yes, please list the condition and give a detailed description of dietary restrictions and reactions. Any dietary conditions or restrictions must be listed on the Health Exam Form by the physician. *

NOTE: We may not be able to accommodate severe
allergies or some dietary restrictions. These will be addressed on a case-by-case basis to
ensure the health and safety of your camper.

What's Next?

Submitting your application:
Your application has not been submitted yet. Please continue reading to complete the consent form and submit your application for review.

Thank you for completing your application! Our Admissions Team will review your application and be in touch soon. We may reach out with additional questions or request additional information. Once the review is complete, you will be advised of the session date(s) we are holding for your camper. These dates are subject to change and subject to the completion of all requested documents and payment.

Payment:
DSHS/DDA Funding:
All DSHS/DDA payments will be pre-authorized by our admissions team. (Do not send a deposit) We will process the necessary paperwork in accordance with their policies and procedures. We may reach out if additional communication/information is required by your case worker.

Private Pay:
A $50 deposit is due at the time of acceptance to hold your space for each camp session. We will send an invoice to the person listed on the application as the billing contact. Payments can be made on the remaining balance, or you can pay in full. Final payment is due no later than June 7, 2026.

Deposits and payments may be paid by check, debit or credit card. Mail checks payable to Lions Camp Horizon to 7506 Gemini St., Blaine, WA 98230. To pay with a debit/credit card, please visit our website and click on the “CAMP” drop-down box located at the top of the home page. Click on “Fees” and follow the prompts to access our secure PayPal link. Please note - PayPal charges a fee for each transaction.

Forms:
You will receive a Health Exam Form via email to be completed by the campers Physician. It is important this form is completed as soon as possible. Reviewing the Health Exam Form is an important step for final approval and securing a space at camp. All camp spaces are “pending” until the receipt of all forms, payment and/or DSHS/DDA approval is completed.

Please review and sign the consent form below.

Parent/Guardian Consent Form

Camper Name: *

Photo/Video Release: Designated staff members take photos of events and activities. Some of these photos may be focused on your camper, or they may be in the background. It is our intention that all photos are a positive reflection of your camper. Photos are posted on our social media during camp sessions to provide families/caregivers with a glimpse into camp life. They may also be used in promotional materials such as brochures, flyers, and website photos. Do you give Lions Camp Horizon permission to use photos and/or video that may contain images of your camper? *

Yes

Consent to Participate:
I give permission for the above-named camper to participate in Lions Camp Horizon activities both on-site and off-site. The activities include, but are not limited to, riding in go-karts or other recreational vehicles, water activities, archery, field games, inclusive sports, bowling, arts & crafts, talent shows, dances, etc. They may also participate in animal activities which may include horseback riding/wagon rides, animal interactions/petting. All animals will be under the supervision of a handler. I understand precautionary measures are taken to safeguard the safety of my camper and agree to hold harmless volunteers and outside agencies who provide entertainment and activities during camp sessions. I acknowledge appropriate safety equipment will be provided as needed and criminal background checks will be completed on any staff members or volunteers who work with my camper.

Consent to Transport:
I authorize Lions Camp Horizon to transport my camper to/from off-site activities using rented vans, WTA buses and/or private vehicles. I acknowledge drivers will be subject to background checks and must provide proof of insurance and a clean driving record.

Consent to Discharge Camper:
The safety of our campers and staff is our top priority. Any campers who do not follow health and safety guidelines will be asked to go home immediately.
I acknowledge my camper may be discharged if he/she engages in any of the following:

Hits, grabs, bites or is overly aggressive towards a camper, staff or volunteer
Inappropriate touching or sexual behaviors
Verbally abusive or uses inappropriate language/gestures
Theft or deliberate property destruction
Inappropriate behavior with guest presenters or
animals
Violates our zero-tolerance policy on tobacco, vaping, alcohol or drugs
Unable to sleep in dormitory setting or disrupts other camper’s sleep.
Emotional outburst, tantrums or refuses to participate at a reasonable level.
Unwilling to comply with health and safety protocols such as handwashing, proper hygiene, wearing protective safety equipment during activities (Head gear, safety glasses, seatbelt, life jacket, etc.)
Develops a fever over 100 degrees, has symptoms such as nausea, vomiting, diarrhea. Shows any signs of a contagious condition.

I understand that Lions Camp Horizon will make every effort to correct behaviors and encourage appropriate
interactions/redirection before discharging my camper. I agree to make immediate arrangements to remove my camper if asked to do so.

By E-signing you agree to the terms above. If you have any questions, please email admin@lionscamphorizon.org

I agree to the Consent Form. *

By e-signing below, I agree to the terms in the Lions Camp Horizon Consent Form (as outlined above). This includes Consent to Participate, Consent to Transport and Consent to Discharge. (In addition, a copy of the consent form will be emailed to you for your records once the application is received).

Signature

Leading up to camp you will receive camp updates and email communication if there are additional items needed from you. Camper packets will be sent out about a month before camp with final information, check-in/check-out times, packing lists and any outstanding items needed. Our office hours are Monday – Friday from 9 am – 3pm. Please feel free to call the office at 360- 371-0531 or contact us via email at admin@lionscamphorizon.org with any questions.

Other Information

Although we can accommodate upwards of 55 campers per session, we are limited to the number of individuals we may accept per session by conditions including, but not limited to, the use of wheelchairs, two-person lifts and transfers, medical treatments, tube feedings and other specialized care. We will do our best to place your applicant in the preferred session, but please bear in mind admission and session placement depends on many factors.

The staff and Board of Directors reserve the right to refuse or cancel enrollment of an individual if we don’t believe we can accommodate the needs of the camper, or, if they pose a risk to himself/herself or others.

Please feel free to provide further information you feel will be helpful for making your camper’s experience stress-free. If this is your camper’s first time attending an overnight camp, we encourage you to schedule a tour of our campus and a meeting with one of our Admission Staff between now and May.

Data Collection Consent *

Name

First Name *

Last Name *