Camp EmpowerApplication

2015

All applications must be received no later than May 15, 2015 at the following address: Attn: Camp Empower 2015

c/o Jennifer Ervin200 Office Park Drive Suite 115B

Birmingham, AL 35223

Camper’s Name: _____________________________________________Age: ___________________________ Date of Birth: _______________

Parent Information:

Contact Information—Mother

Contact Information—FatherMedical Insurance Information

Emergency Contact Information

Child’ Profile

First Name Middle Name Last Name Date of Birth Current Age Biogogical/Adopted/Foster

Sibling Information

First Name Current Age Biological/Adopted/Foster

If adopted date of placement

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Is there a history of abuse, neglect, trauma or significant separations? 

Medical History—Camper

1. Does the camper have any medical or physical diagnoses?

Label Date ofDiagnosis

Current Medications(if any)

Comments

Diagnosis 1

Diagnosis 2

Diagnosis 3

Diagnosis 4

Diagnosis 5

2. Does the camper have any know allergies or food restrictions?

( ) yes ( ) no

If yes please explain:

3. Has the camper received any psychological diagnoses (e.g. ADD/ADHD, Autism, ODD, depression, bipolar,etc.)?

( ) yes ( ) no

If yes, please explain:

Describe any medical problems your child has experienced: eg. inner ear problems, colic, hospitalizations, premature birth, lack of prenatal care, etc. not already listed.

Educational Profile—Camp

1. Has your child ever been referred for testing or placed in a special program?

( ) yes ( ) no

If yes, please explain:

2. Has your child ever received any other special help or tutoring?

( ) Yes ( ) no

If yes, please explain:

3. Does the camper have behavioral difficulties?

( ) yes ( ) no

If yes, please explain:

4. Does the camper have sensory difficulties?

( )yes ( ) no

If yes, please explain:

6. Does the camper have social difficulties?

( ) yes ( ) no

If yes, please explain:

7. Has the camper ever seen a counselor/doctor/psychiatrist for any type of social, behavioral, or mental problems?

8. Has your child had vision therapy, reflex therapy or sound therapy in the past?

( ) Yes ( )NoIf yes, where and how long?

10. Please describe your child’s character strengths and weaknesses.

11. Please list three goals you have for the camper during camp.

12. Does Camp Empower have permission to contact your child’s psychologist? Counselor? Former teachers?

( )Yes ( )No

Psychologist/counselor’s name and phone:

Former teacher’s name and phone:

I/we attest that to the bed of my/our knowledge, all of the information above is correct and I/we have disclosed all information honestly to questions as documented on this form. If selected as one of the participants of Camp Empower 2-015, I/we agree that both parents will read “The Connected Child” book prior to the start of camp. In addition, I/we will attend two parenting equipping nights during the week of camp.

I/we have read and fully understand this agreement. A deposit of $250 is required with the application and will be refunded if the camper is not chosen as a participant.

__________________________________________ _____________Parent Signature Date

__________________________________________ _____________Parent Signature Date