Camp Jubilee Camper Application 2024

GENERAL INFORMATION

For which week of camp are you registering?(Required)

Camp Week Preference

Please let us know your top choice of camp week in the case our registrations fill up and we are unable to accommodate your camper attending both camps.

Mountain Top Youth Camp (June 30 - July 4)

Betsy Jeff Penn 4H Center (August 4 - 8)

Camper's Name(Required)

First Last

Nickname

T-Shirt Size(Required)

Gender(Required)

Height(Required)

Weight(Required)

Birthdate(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Church Affiliation?

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Email(Required)

Primary Phone Number(Required)

Secondary Phone Number(Required)

Emergency Contact Name (someone other than parent)(Required)

First Last

Emergency Contact: Relationship to Camper(Required)

Emergency Contact: Primary Phone Number(Required)

Emergency Contact: Secondary Phone Number(Required)

Emergency Contact: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact: Preferred Email(Required)

MEDICAL HISTORY

Primary Diagnosis(Required)

Secondary diagnosis

Any other medical diagnosis(Required)

Please describe camper’s general health, including special medical problems, diagnosis and/or disabilities:(Required)

Please describe the camper's social/emotional state most of the time (for example: withdrawn, hyper-verbal, frustrated, sociable, even-tempered, etc.)(Required)

Does your camper have Down Syndrome?(Required)

If your camper has Down Syndrome please complete the next section. There is a medical condition called atlantoaxial subluxation instability. This condition is a weak cervical vertebrae that could lead to paralysis if injured. It is reported that 30% of people with DS have this condition, and it is often undiagnosed. Having the utmost precaution, we are requesting that each camper with DS have permission from their Primary Care Physician to participate in horseback riding. If you do not get clearance from your PCP, a parent or guardian will be required to sign a waiver that gives their child permission to participate in horseback riding. Or you can simply opt your child out of horseback riding. If your Camper has down syndrome, please select from the following:(Required)

Please sign below to acknowledge parental consent to the question above(Required)

NOTE: Typing your name will be treated as your signature and is binding!

Has the applicant had more than a brief illness during the past three years?(Required)

If yes, when? Please describe:(Required)

HEALTH HISTORY

If the camper is prone to (or has had) problems with any of the following, please indicate YES or NO. If yes, explain in space provided. List preferred treatment if applicable.

Eye Problems(Required)

Yes

Ear Problems(Required)

Yes

Hearing Problems(Required)

Yes

Headaches(Required)

Yes

Chest infections(Required)

Yes

Asthma(Required)

Yes

Epilepsy/seizures(Required)

Yes

Scoliosis(Required)

Yes

Heart trouble(Required)

Yes

Kidney Disease(Required)

Yes

Stomach Trouble(Required)

Yes

Tuberculosis(Required)

Yes

Diabetes(Required)

Yes

Diarrhea or Constipation(Required)

Yes

Fainting Spells(Required)

Yes

Menstrual Problems(Required)

Yes

Muscle Problems(Required)

Yes

Neurological Problems(Required)

Yes

Emotional Problems(Required)

Yes

Psychological Problems(Required)

Yes

Psychiatric Problems(Required)

Yes

HIV(Required)

Yes

Hepatitis(Required)

Yes

Other

Yes - details below

Other: Please List

If you selected YES for any of these question, please explain in space provided. List preferred treatment if applicable.

QUESTIONS ABOUT THE CAMPER

Can the camper swim?(Required)

Yes

Please provide additional information if needed.

Is the camper actively involved in any of the following activities?

Tobacco Use

Drug Use

Criminal Activity

Sexual Activity

If yes please explain(Required)

Please describe activities and/or situations that the camper strongly dislikes(Required)

How does the camper respond to situations they don’t like or that upsets them?(Required)

What techniques are used to de-escalate behaviors?(Required)

Has the camper ever exhibited behaviors such as hitting, yelling, throwing, biting, or making verbal threats, etc? If so, what seems to trigger these behaviors?(Required)

Please describe activities and/or situations that the camper enjoys:(Required)

Please describe your goals and expectations for the camper and what you hope Camp Jubilee can accomplish:

Please check which of the following apply to the camper:(Required)

Likes people

Gets along well with friends

Follows directions willingly

Shows concern

Prefers alone time

Respects rights & property of others

Gets angry easily

Tends to be shy initially

Can get easily agitated/irritable

Gets anxious

Has self-stimming behaviors

Does not perseverate

Can introduce self

Forms close relationships

Is generally happy

Select all that apply

Other: Please Explain

Select all that apply to campers sensitivities(Required)

Sensitive to light

Sensitive to touch

Sensitive to sound

N/A

Which of the following apply to the campers speech/language and communication skills?(Required)

Speaks Spontaneously

Can make wants and needs known

Uses complete sentences

Has small vocabulary

Uses sign language

Understands lengthy dialogue

Makes little or no effort to communicate verbally or with gestures

Understands short, direct commands

Communicates by writing

Comprehends written statements

Uses gestures effectively

Uses sentences effectively

If using a communication device, please explain:

MEALS(Required)

No assistance needed

Total assistance needed

Some assistance needed

Needs a straw for liquid

Food needs to be cut/chopped

Special Meals Instructions:

MOBILITY(Required)

Walker

Braces/Crutches

Manual wheelchair

Electric wheelchair

Not able to stand for prolonged periods of time

Comprehends written statements

Has physical limitations that limit participation in activities

No assistance needed

Does the camper use any assistance with walking or moving?

Special instructions for mobility:

SHOWERING(Required)

Special Instructions for Showering:

DRESSING(Required)

Special Instructions for Dressing:

Toileting(Required)

No assistance needed

Help transferring

Help cleaning up

Wets bed

Diapers /depends

Assistance needed only after a bowel movement

Bowel Control(Required)

Bladder Control(Required)

Special Instructions for Toileting:

SLEEPING(Required)

Soundly

Gets up throughout the night

Uses the bathroom during the night

Scared of the dark

Uses a C-pap machine

Special Instructions for Sleeping:

AIDS & DEVICES

Does the camper use any of the following:

Glasses

Hearing Aids

Prosthetics

None

Other: Please explain

INSURANCE INFORMATION

Provider(Required)

Primary Subscriber(Required)

Policy Number(Required)

Group Number(Required)

Effective Date:(Required)

MM slash DD slash YYYY

PHYSICIANS

Name of Campers primary physician:(Required)

First Last

Office Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Date of last physical exam:(Required)

MM slash DD slash YYYY

MEDICATIONS

Is the camper on any regular medications or supplements?(Required)

Be sure that an adequate number of medications are sent in the original prescription containers, with the camper’s name and instructions on the bottle. Be sure that the dosage on this application and on the bottles are the same. This information is very important so we can adapt to special needs when we are aware of them. Medications are to be put in a separate bag, marked “Nurse.” Please do not give campers their own bottles of aspirin, cough syrup, etc.

Medications list(Required)

Name

Dosage/Frequency

Prescribed by

Date Prescribed

Reason for Medication

Medications list

Name

Dosage/Frequency

Prescribed by

Date Prescribed

Reason for Medication

Medications list

Name

Dosage/Frequency

Prescribed by

Date Prescribed

Reason for Medication

Medications list

Name

Dosage/Frequency

Prescribed by

Date Prescribed

Reason for Medication

Medications list

Name

Dosage/Frequency

Prescribed by

Date Prescribed

Reason for Medication

Medications list

Name

Dosage/Frequency

Prescribed by

Date Prescribed

Reason for Medication

ALLERGIES & RESTRICTIONS

Is the camper allergic to any medications(Required)

If yes, please list:

Does the camper have any other allergies or sensitivities: food, pollens, insect bites, etc?(Required)

If yes, describe what allergies/sensitivities, reactions, and what treatment is usually necessary.

Does the camper use an Epipen?(Required)

If yes, one must be supplied by the camper.

Does the camper have any dietary restrictions?(Required)

If yes, please list:

ADDITIONAL INFORMATION

If there is any further information you feel should be provided which is a factor and could influence the care, health, and well-being of this camper at Camp Jubilee, please explain:

FINANCIAL INFORMATION

Camp Jubilee strives to provide camp as cost effectively as possible. The tuition costs cover approximately 50% of our camp operating costs. MJM is happy to provide financial assistance to those in need and to those who qualify.

Mountain Top Youth Camp - $50 non-refundable application fee + $250 Camp Tuition.

Betsy Jeff Penn 4H Center - $50 non-refundable application fee + $350 Camp Tuition.

Do you require tuition assistance?

If so, you will be contacted after your camper is admitted to camp and we will be glad to discuss available options based on your unique circumstances.

Yes

PERMISIONS

Select all as applicable.

Select All Acceptable Permissions(Required)

I give permission for my camper to be checked for lice.

I give permission for my camper to be included in photos that may be used for marketing.

I give permission for my camper to receive any medical treatment necessary for their health and well-being.

I give permission for my child to be transported by MJM staff and/or volunteers for medical emergencies.

Authorized Signature(Required)

NOTE: Typing your name will be treated as your signature and is binding!