Day Camp Intake Form

Please complete this intake form for Lions Camp Horizon day camp. If you have questions before submitting, email acd@lionscamphorizon.org.

Parent/Caregiver Information

Name (person completing the application) *

Relationship to camper *

Email *

Phone number *

How did you find out about our day camp program? *

Lions Camp Horizon website

Social Media

A friend, caregiver, or teacher

A case manager, doctor, or therapist

Transition fair or career fair

Disability resource list

Other

Camper Information

Camper's Full name *

Preferred name, if different from legal name

Date of birth *

Primary diagnosis *

Other diagnoses or chronic conditions

Has the camper previously attended the Lions Camp Horizon summer camp program? *

Yes

I'm not sure

Day Camp Questions

What form of payment will be used? *

Private Pay

DSHS/DDA Respite Hours

PAVE Waiver

Other

Who will be responsible for bringing the camper to and from the day camp program? *

Myself (person completing application)

Approved family/friends

Home/living facility care staff

Public transportation

Other

Authorized drop-off and pick-up names and contact information

How frequently do you want the camper to attend the day camp program? Please note that this will not commit you to a certain number of sessions. *

Twice a month

Once a month

Once or twice this year

Depending on availability

I'm not sure yet

Please confirm you understand that day camp drop-off is at 9:00AM and all campers should arrive within 15 minutes of that time. *

Yes, I understand

I will need a later drop-off time

Please confirm you understand that day camp pick-up is at 4:00PM and all campers should be picked up within 15 minutes of that time. *

Yes, I understand

I will need an earlier pick-up time

What core curriculum areas are you and the camper interested in exploring at our day camp program? *

Vocation/Employment Skills

Education

Independence Skills

Social Skills

Other

Camper Care Needs

Does the camper need a 1:1 or 2:1 camper to staff ratio for adequate care? This ratio may be adjusted after the camper attends a trial session. *

Yes

I'm not sure

Does the camper exhibit any challenging behaviors such as running away, throwing objects, verbal aggression, physical aggression, etc.? *

Yes, frequently

Yes, but only in certain situations

Rarely

No, never

Does the camper have any allergies we should be aware of, including food, environmental, or products/medications?

Will the camper need to take medication or receive routine treatment during day camp hours, not including emergency response medications such as an epi-pen or inhaler? *

Yes, and the camper will need assistance with this

Yes, and the camper will take care of this independently

The camper has complex medical needs requiring a full-time nurse or specially trained caregiver

No, any medication/treatment will be done outside of day camp hours

Other

Notes about medication, treatment, or medical support needs

Personal Growth Plan Questions

If applicable, please describe the camper’s short-term and long-term vocation/employment goals

If applicable, please describe the camper’s short-term and long-term education goals

If applicable, please describe the camper’s short-term and long-term independence goals

If applicable, please describe the camper’s short-term and long-term social skills goals

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, or wearing protective safety equipment during activities
Develops a fever over 100 degrees, has symptoms such as nausea, vomiting, or diarrhea, or shows signs of a contagious condition

I understand that Lions Camp Horizon will make every effort to correct behaviors and encourage appropriate interactions and 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 outlined above. This includes Consent to Participate, Consent to Transport, and Consent to Discharge.

Signature *

Data Collection Consent *

I consent to my submitted data being collected and stored.

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