Camper Application Request - DAY CAMP

thank you for your interest in Handi*Camp. To receive a prospective camper application packet, please read the following and complete the form below.

Confidentiality and Consent Information: Handi*Camp is committed to protecting your privacy. The information provided below will be used to evaluate care needs and determine the appropriate camp session for each prospective camper. Information provided will only be shared with relevant Handi*Camp personnel. By submitting this form, you consent to the collection, storage, and use of the camper’s information. If you are NOT comfortable providing this initial information online, please CALL our office to speak with a camp staff member who will be happy to assist you in completing this form by phone. (717.859.4777)

NOTE: Once you receive your forms, complete them as soon as possible. ALL forms are DUE AT THE CAMP OFFICE no later than MAY 16, 2025. Earlier is better, as spaces fill “first-come, first-served” based on the final completion date of ALL your forms.

Prospective camper:

First Name

Last Name

Camper's birthdate:

YYYY

Camper's age:

Camper's gender:

Camper's disability:

Please describe. If none, type "none."

Is there any INTELLECTUAL component to camper's disability?

Has camper attended HANDI*CAMP before?

Primary contact for paperwork:

First Name

Last Name

Relationship to prospective camper:

Primary contact's phone number for application process:

(###)

###

####

Mailing address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Be sure this is an ACTIVE, MONITORED email. Handi*Camp will use this address to correspond with you during the application process.

In the last five years, has prospective camper had ANY SEIZURE ACTIVITY and/or been diagnosed with a SEIZURE DISORDER?

If YES, an additional SEIZURE FORM will be included in your packet.

In the last five years, has the prospective camper had a diagnosis of ASTHMA and/or used an INHALER?

If YES, an additional ASTHMA FORM will be included in your packet.

In the last five years, has the prospective camper been diagnosed with DIABETES or PRE-DIABETES?

If YES, an additional DIABETES FORM will be included in your packet.

Does prospective camper have a feeding tube?

If YES, an additional FEEDING TUBE FORM will be included in your packet.

Will the prospective camper need ANY MEDICATIONS or TREATMENTS (prescription, PRN, etc.) while at camp?

If YES, an additional MED FORM will be included in your packet.

Additional comments:

Handi*Vangelism Ministries International

Handi*Vangelism Ministries International

Camper Application Request - DAY CAMP

Handi*Vangelism Ministries International

Camper Application Request - DAY CAMP

thank you for your interest in Handi*Camp. To receive a prospective camper application packet, please read the following and complete the form below.

NOTE: Once you receive your forms, complete them as soon as possible. ALL forms are DUE AT THE CAMP OFFICE no later than MAY 16, 2025. Earlier is better, as spaces fill “first-come, first-served” based on the final completion date of ALL your forms.

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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