Camp Empower Registration

Camper's Name*

First NameLast Name

Grade*

Date of Birth*

Mother's Full Name*

First NameLast Name

Father's Full Name*

First NameLast Name

Camp Empower Location*

Camp Empower Columbus is full. You may still apply to join the waitlist or email jeeahshope@gmail.com to express interest. We’re already praying about a second session next summer.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Father's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Father's Cell Phone Number*

Please enter a valid phone number.

Parents live at the same address*

YesNo

Mother's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mother's Cell Phone Number*

Please enter a valid phone number.

What is your insurance carrier?*

Policy Number*

Group Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Name*

First NameMiddle NameLast Name

Please select one*

BiologicalAdoptedFoster

Doe the camper have any medical or physical diagnoses?*

If so, please list them below. (Please include the date of diagnosis)

Please list any medications the camper is currently taking for these diagnoses.

Does the camper have any known allergies or food restrictions?*

YesNo

If so, please explain

Has the camper received any psychological diagnoses? (e.g. ADD/ADHD, Autism, ODD, Depression, Bipolar, etc.) **

YesNo

If so, please explain

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

Please describe any medical problems your child has experienced (e.g. inner ear problems, colic, hospitalizations, premature birth, lack of prenatal care, etc.) if not already listed.

Has your child ever been referred for testing or placed in a special program? If so, please explain below. *

Has your child ever received any other special help or tutoring? If yes, please explain below. *

Does the camper have behavioral difficulties? If yes, please explain.*

Does the camper have sensory difficulties? If yes, please explain. *

Does the camper have social difficulties? If yes, please explain.*

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

Have they ever been hospitalized for psychological issues? *

Has your child had vision therapy, reflex therapy, or sound therapy in the past? If yes, where and for how long? *

Please describe your child's major strengths and major difficulties.*

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

Does Camp Empower have permission to contact your child's psychiatrist? Counselors? Former teachers?*

CounselorTeacherPsychiatristAll of the above

Psychiatrist/Counselor/Teacher Name and Contact Info.

I/we attest that to the best 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, I/we agree that both parents will read “The Connected Child” book prior to the start of camp. In addition, I/we will attend one parent equipping night during the week of camp. I/we have read and fully understand this agreement.*

Agree

Child's Profile