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Camp 2027
March Break Camp 2027
Destinations
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Participant First Name
*
Participant Last Name
*
Caregiver Email
*
Caregiver Phone
*
Participant Birthday
*
Year
Month
Month
Day
Address
Emergency Contact
*
Emergency Phone
*
In case of medical emergency I give permission to Zachary's Camp to secure treatment through Emergency Medical Staff. All efforts will be made to contact caregiver or emergency contact
*
YES
NO
Doctor's Name and Phone Number
*
Health Card Number
*
Participant's Diagnosis
Recent Illness
Allergies
Medication
*
YES (requires separate form)
NO medication needed
Has the participant ever had or currently has seizures?
*
Assistive Devices:glasses, hearing aid, communication devices
Toileting & Feminine Hygiene
*
Independent
Needs assistance
Dressing
*
Independent
Assistance
Swimming
*
confident swimmer-deep end
confident in the water-shallow end and able to touch ground
Swim Vest-at the beach we requiere vests for everybody if waves are present
Scared of water
Zachary's Camp would like the oppurtunity to post pictures taken during 20025/2026. No Names or exact locations will be posted
*
I DENY permission to use participants picture at all
I GRANT permission for UNRESTRICTED USAGE of all participants' pictures
Limited permission
Is there any information we should have in order to safely support the participant?
Submit
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