Please complete the following form with information on the prospective camper. A Handi*Camp staff member will contact you soon to answer any questions you may have and to send you additional information.

Prospective Camper NAME

First Name

Last Name

Prospective Camper Date of Birth

(used to determine appropriate session)

YYYY

Prospective Camper's Age

Prospective Camper Gender

Prospective Camper's Disability/Diagnoses

Prospective Camper's Intellectual Disability Level

Prospective Camper's School/Grade Level

If prospective camper is in school, please provide GRADE LEVEL and/or DESCRIBE TYPE of SPECIAL EDUCATION PROGRAM, if applicable.

Primary Contact Name For Paperwork

First Name

Last Name

Relationship To Prospective Camper

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email Address

Additional Comments or Message

Handi*Vangelism Ministries International

Handi*Vangelism Ministries International

Camper Interest Form

Handi*Vangelism Ministries International

Camper Interest Form

Handi*Vangelism Ministries International

MAILING ADDRESS: PO Box 122, Akron PA 17501-0122

physical Headquarters: 3261 ROTHSVILLE ROAD, AKROn pa 17501

CONTACT US | PHONE: 717.859.4777

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