2016 CAMP WEEKANEATIT CAMPER APPLICATION


SPACE IS LIMITED....FIRST COME, FIRST SERVE---ALL APPLICATIONS MUST BE COMPLETED BY MARCH 15, 2016

Please complete this camper application and submit with fee to reserve a spot at Camp Weekaneatit 2016:  May 29 - June 3, 2016  for 8-17 year olds with Celiac Disease or Gluten Intolerance and their siblings.  This camp will be held at the Camp Twin Lakes, Camp Dream facility in Warm Springs, Georgia.

Once we have received this application online AND  the registration fee--which you can submit through Pay Pal on our www.glutenfreecamp.org  site or through the mail, we will review the application and you will be notified when you have been accepted to this years’ camp program.  You must have your registration fee in before your spot is reserved.  If you need a payment plan, you may still go through our PayPal link and apply through that link for a payment plan.  Once you have made that arrangement, we will receive notice and consider you paid, for our purposes.  Your payment plan agreement is between you and PayPal.

Applications will be accepted on a first come, first served basis.  There is a limited number of campers so reserve your spot early!   Applications are due BEFORE MARCH 15, 2016.  Please note the fee structure which gives discounts for additional campers in the same family.
DO NOT MISS THE EARLY BIRD REGISTRATION OPPORTUNITY...REGISTER BY JANUARY 30, 2016 TO RECEIVE THE FOLLOWING EARLY BIRD FEES :
 
PAYMENT AND APPLICATION BY JANUARY 30, 2016:  
First Camper:  $550  
Each Additional Camper from the same family:  $500

Please submit payment through the PayPal button on the www.glutenfreecamp.org site (make certain to include your camper name in the payment form) --there will be a processing fee you will be charged to use PayPal.
OR
Please make check payable to The Georgia Celiac Foundation/ with Camp Weekaneatit AND your camper name(s) in the memo line.  Mail your camp fee to:

Mary Bohdan  
100 Tall Timber Court
Fayetteville, GA 30215

After we are in receipt of this application AND your fee  (online verification of payment/agreement or cleared check), we will review your application and notify you of your acceptance.  You will then be asked and directed to complete additional forms and supply additional information.  

For any questions, please call or email Mary Bohdan at:
770-716-7682
campweekaneatit@gmail.com 


AT THE END OF THIS APPLICATION BELOW, MAKE SURE TO PRESS SUBMIT.  IF YOU DO NOT GET A THANK YOU, YOUR FORM HAS NOT BEEN SUBMITTED.  LOOK DOWN THE FORM AGAIN AND ANSWER ANY QUESTIONS HIGHLIGHTED IN RED THAT WERE REQUIRED QUESTIONS.    PRESS SUBMIT AGAIN!
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Camper's  Name *
Preferred Name for Name Tag
Date of Birth *
Age *
Please indicate age camper will be at camp.
Grade *
Please indicate current grade in school.
Sex *
Social Security Number *
FORM YOU WILL BE SUBMITTING YOUR CAMPER FEE *
If submitting payment or payment plan through PayPal, please indicate here the name on credit card used *
this is to ensure that your payment goes toward your camper
Parent/Guardian Name *
Relationship to Camper
Street Address
City
State
Zip Code
Primary Phone *
Secondary Phone
Other Phone
Email Address *
Note:  All correspondence will be communicated via email, so please check your email for updates!
Secondary Email Address
Please complete only if you want correspondence sent to this account.
Emergency Contact Name *
Person to be contacted in case of emergency if parent/guardian cannot be reached.
Relationship to Camper
Emergency Contact Primary Phone *
Emergency Contact Secondary Phone
Emergency Contact Other Phone
Insurance Company Name *
Phone *
Address
City
State
Zip Code
County
Policy Number
Are you a Celiac/Gluten Intolerant camper or the sibling? *
If you are a sibling, indicate the Celiac's name.
Date of Diagnosis of Celiac Disease *
If you are a sibling, indicate "sibling."
Diagnosing Physician's Name *
If you are a sibling, indicate "sibling."
Briefly Describe Reaction to Gluten *
If you are a sibling, indicate "sibling."
Dietary Restrictions *
If other, please describe. *
Note:  We will do our best to accommodate additional dietary restrictions other than GF.   However, please only list those that are MEDICALLY necessary for your child
Medication Allergies *
List all known.  Describe reaction and management of the reaction.
Food Allergies *
List all known.  Describe reaction and management of the reaction.  
Other Allergies. *
List all known.  Include insect stings, hay fever, asthma, etc.  Describe reaction and management of the reaction.
Has your child/Does your child.... *
If yes, check the box.
Required
If you answered yes to any of the above, please explain.
Which of the following has your child had? *
Please note:  If you child has been exposed to any communicable disease, particularly chicken pox, measles, or mumps, 1 to 3 weeks prior to camp, please contact us as soon as possible.  
Required
IMPORTANT REQUIREMENT-all campers are REQUIRED to have proof of vaccinations.  You must submit your child's immunization records once you are accepted to camp *
Please indicate below if your camper is up to date on immunizations.  YOU MUST SUBMIT YOUR UPDATED IMMUNIZATION VERIFICATION FORM.  PLEASE UPLOAD AND EMAIL
Required
If no, please explain.
Medication
The medical staff will store and administer any medications needed during the camp week.  PLEASE SEND ALL MEDICATIONS TO CAMP WITH YOUR CHILD IN THEIR ORIGINAL CONTAINER WITH WRITTEN INSTRUCTIONS.  It is expected that each family will supply in advance any routine medications needed.  Specific instructions on how to send medications and the medication check-in process will be sent to you closer to camp.
Check one of the following boxes. *
List each medication name, dosage, and frequency.
Name of Pediatrician *
Pediatrician's Phone Number *
Name of GI *
GI's Phone Number *
Does your child use any special equipment such as a walker, crutches, wheelchair, or prosthesis?  Please explain.
Please list any physical restrictions or activity limitations (i.e. no swimming, no prolonged sun exposure, no competitive sports, sight or hearing loss, etc.).
Is there anything we should know about your child that will make his/her adjustment smoother?
Is your child able to function at his or her age level?  Please describe.
Describe any bedtime or sleep habits (eg. sleeps with parent, toys, talks/walks/ in sleep, etc.).
Does your child have any serious fears?  Please describe.
Please indicate any further information about your child's medical and/or emotional needs that you feel we should know. Please include if your child sees a psychiatrist or psychologist regularly.
Camper's T-shirt Size
If your child would like to share a bunk room with a friend or sibling, please list by name.
REQUESTS WILL ONLY BE CONSIDERED FOR CAMPERS IN THE SAME AGE RANGE and will be assigned at camper check-in.  NOT GUARANTEED!
Where did you hear about our camp?
If you would like to be considered for a limited number of scholarships, please provide an explanation of need.
BE SURE TO CLICK SUBMIT!!!!!
MAKE SURE TO PRESS SUBMIT. THEN,  IF YOU DO NOT GET A THANK YOU, YOUR FORM HAS NOT BEEN SUBMITTED.   LOOK DOWN THE FORM AGAIN AND ANSWER ANY QUESTIONS HIGHLIGHTED IN RED THAT WERE REQUIRED QUESTIONS.  
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