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2021 Camper Application

Step 1 of 7 - Camper Background

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Hello Casey Bunch! We are so excited to see you again this summer! We are planning on an in-person day camp at Seattle’s Magnuson Park (subject to change) the week of July 26-30. Please save the week of July 26 and we will finalize dates for your camper closer to camp. Depending on the number of applications, we are expecting to hold a 1 or 2 day day-camp for your camper (8:30/9:00am drop off and a 4:00pm pick up). Please note we will be following CDC Guidlines (link) for large gatherings. We miss you and can’t wait to see you!

If you require assistance completing any part of the application due to language or accessibility needs, please email director@campcasey.org so appropriate accommodations can be arranged.
Please completely fill-out this application to assist us in caring for the camper as safely as possible and so we may ensure the camper has a wonderful week at camp.

Near the end of this application, you will have an opportunity to submit medically relevant pictures that you believe would help us care for the camper (eg. AFO and sleep positioning). It is recommended that you prepare these before beginning the application.

After submitting this application, you will be contacted by a camper application committee member who will notify you regarding the status of your application.

If anything regarding the care of the camper changes between now and the start of camp, please contact your camper application committee member so we can have the most up-to-date information.
Will the camper be between the ages of 6 and 19 years old on July 26, 2021?*
Due to popularity and accommodations, we have to limit the ages of campers to those between 6 and 19 years old.

NOTE: We are only expanding the age requirements this one year to accommodate campers who were unable to graduate last year.
- Yes
- No
Is the camper's disability primarily physical in nature?*
- Yes
- No
Is the camper able to communicate basic needs and interests to people they do not know, even if it is non-verbally? Please note: volunteers are not all trained with ASL – American Sign Language.*
- Yes
- No
Does the camper use safe behavior for themselves and others? (We cannot accommodate children who have biting, kicking, punching or physical abusive behaviors. Campers need to stay with the group without one to one assistance. We average a two camper to one counselor ratio.)*
- Yes
- No
Has the camper been to Camp Casey before?*
- Yes
- No
We regret to inform you Kiwanis Camp Casey is a one-week summer camp for children ages 6 to 17 years of age who have the following characteristics.

1) Their disability is primarily physical.

2) They can communicate and engage with people they are not familiar and communicate basic needs and interests. Children who are non-verbal but have a clear yes and no and engage with other children at a cooperative play level are appropriate Kiwanis Casey Campers.

3) The camper must use safe behavior both for themselves and others.

As an all-volunteer non-profit, we are limited in our ability to provide direct one to one supervision and specialized training for our counselors which we feel the camper would need for a safe overnight camp experience.

One reference which may prove helpful in your search for summer camps is the resource listed in the Parentmap Magazine

We wish you the very best.

If you have further questions, please email the camp director at director@campcasey.org

Name:*
First Last Name Camper Goes By
Sex:*
- Male
- Female
Height & Weight:*
Feet Inches Weight
Date of Birth:*
MM slash DD slash YYYY
Age when Camp starts (years):*
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian (This will be the first Parent/Guardian contacted by the Kiwanis):*
First Last Relationship to Camper
Parent/Guardian's Email:*
Parent/Guardian Primary Phone:*
Type Phone
Parent/Guardian Secondary Phone:
Type Phone
Parent/Guardian:
First Last Relationship to Camper
Parent/Guardian Primary Phone:
Type Phone
Parent/Guardian Secondary Phone:
Type Phone
Parent/Guardian's Email:
Additional Email for Communications:
Camper's Email:
Do you, as a parent/guardian of the camper, give permission for a member of the Kiwanis Camp Casey Camper Application Committee to contact the applicant's teacher/alternative via email or phone?*
- Yes
- No
Completion of a teacher questionnaire is required for each new camper applicant. If you have any questions about this process please email the camp director at: director@campcasey.org
Please provide the contact information of the teacher/alternative.*
First and Last Name Phone Email
Emergency Contacts
In case of emergency where the parents or guardians cannot be reached, please list a contact person.

The contact should be able to make decisions and pick-up or make arrangement to pick-up the camper if needed.
First Emergency Contact:*
First and Last Name Relationship Phone
Second Emergency Contact:
First and Last Name Relationship Phone
Third Emergency Contact:
First and Last Name Relationship Phone

Medical Information
Please provide medical contact information for the physician most familiar with the camper's care.
Insurance Name, group number, member ID:*
Insurance Phone Number:*
Physician Information:*
Physician Name Physician Phone
Primary Disability/Medical Diagnosis:*
Resulting Physical Disability:*
Resulting Mental Disability:*
Does the camper have a school IEP?*
- Yes
- No
Please indicate if there are IEP Goals in the following:
- Physical
- Self-Help
- Academic
- Social
- Behavior
Please Provide Camper's Physical IEP Goals.*
Please Provide Camper's Self-Help IEP Goals.*
Please Provide Camper's Academic IEP Goals.*
Please Provide Camper's Social IEP Goals.*
Please Provide Camper's Behavior IEP Goals and Behavior Plans.*
In what type of classroom does the camper receive most of their education?*
- General Ed
- Resource Room
- Self Contained (please describe)
- Other (please describe)
Please describe self contained classroom education.*
Please describe other classroom education.*
Does the camper have any allergies?*
- Yes
- No
Types of allergies and reactions. (Food dislikes are listed elsewhere.)*
- Allergies to Medicines
- Allergies to Foods
- Other
Please describe all allergies and reactions.*
Is the camper up to date on immunizations?*
We strongly encourage campers to be up to date on their immunizations to help prevent the spread of preventable diseases while at camp and in the community. This question does not apply to COVID-19 vaccinations.
- Yes
- No
- My child is not immunized
We strongly encourage campers to be up to date on their immunizations to help prevent the spread of preventable diseases while at camp and in the community.
Is your camper vaccinated for COVID-19?*
- Yes
- No
Please note this is not a requirement. We cannot guarantee all campers will be vaccinated for COVID-19
Do you anticipate your child will be fully vaccinated for COVID-19 by the time camp starts?*
- Yes
- No
Please note this is not a requirement. We cannot guarantee all campers will be vaccinated for COVID-19
Is your camper able to wear a face covering and keep it on?*
- Yes
- No
- Only for short periods of time
Is your camper allergic or reactive to common sanitizing products?*
(i.e. Hydrogen poroxide, Aloe, bleach)
- Yes
- No
Please explain which products/materials your camper is allergic to.*
Please Note: We will only be administering medications which are taken between the hours of 9am and 3pm, but information about all medications would be greatly appreciated.
Does the camper take any medications?*
- Yes
- No
First medication:*
Medication Name Dose (Number only, units entered later)
First medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
First Medication Schedule:*
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the first medication.*
Second medication:
Medication Name Dose (Number only, units entered later)
Second medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Second Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the second medication.*
Third medication:
Medication Name Dose (Number only, units entered later)
Third medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Third Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the third medication.*
Fourth medication:
Medication Name Dose (Number only, units entered later)
Fourth medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Fourth Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the fourth medication.*
Fifth medication:
Medication Name Dose (Number only, units entered later)
Fifth medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Fifth Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the fifth medication.*
Sixth medication:
Medication Name Dose (Number only, units entered later)
Sixth medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Sixth Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the sixth medication.*
Seventh medication:
Medication Name Dose (Number only, units entered later)
Seventh medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Seventh Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the seventh medication.*
Eighth medication:
Medication Name Dose (Number only, units entered later)
Eighth medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Eigth Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the eighth medication.*
Ninth medication:
Medication Name Dose (Number only, units entered later)
Ninth medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Ninth Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the ninth medication.*
Tenth medication:
Medication Name Dose (Number only, units entered later)
Tenth medication dosage units
- mg
- mL
- mcg
- grams
- Pills
- Units
- Tabs
Tenth Medication Schedule:
- Breakfast
- Lunch
- Dinner
- Bedtime
- Other
If Other, please specify time below
Please explain the schedule for the tenth medication.*
If you have any additional medication entries, please enter them below by listing the name, dosage and schedule of the medication.
Please list any special medication instructions below.
Occasionally, campers may need certain over the counter (OTC) medications for minor ailments (headache, allergy, cough & cold, constipation, etc) while at camp. If you permit, our nurses will administer the appropriate OTC medication per their clinical judgement. Please indicate your preferences to allow our nurses to administer OTC medications if they feel it necessary:*
- Yes, I give permission for my child to receive appropriate OTC medications administered by the nurse.
- No, do not give any OTC medication without prior consent.
Please specify if there are any special instructions for administering OTC medications
Does the camper take medications with special foods?*
- Yes
- No
Please provide special food requirements for medication and provide enough to last the day(s) that your camper is attending Camp Casey..*
Please note you'll be required to supply whatever is necessary for your camper to take this medication on the day/s your camper attends camp
ALL Medications must be given to the nurses at check in. DO NOT PACK your child’s medications.*
- I acknowledge I have read the above statement

SPECIAL NURSING CARE OR CONCERNS
Does the camper have a VP shunt?*
- Yes
- No
If yes, describe any special monitoring or care required.*
Does the camper have history of seizures or blackouts?*
- Yes
- No
When was the last occurrence of a seizure or blackout?*
Please enter a best guess if exact date is unknown
MM slash DD slash YYYY
If the camper does have a seizure or blackout at camp, we will contact you immediately. In the event we cannot reach you, please tell us what would warrant a visit to the emergency department.*
Has the camper had any recent surgeries that will impact care at camp?*
- Yes
- No
If yes, describe nature of surgery, including date(s).*
Does the camper have open sores or wounds that will require care at camp?*
- Yes
- No
If yes, describe location and required care (be sure to send PLENTY of wound care supplies).*
Is nasal congestion normal for the camper?*
- Yes
- No
How is this treated at home?*
Does the camper have problems with stomach upset?*
- Yes
- No
If yes, what treatment is used (please send meds used)?*
Does the camper have problems with muscle cramps?*
- Yes
- No
If yes, what treatment is used?*
Does the camper have appliances, retainers, contact lenses, glasses, etc. requiring special care?*
- Yes
- No
Please describe.*
Does the camper sunburn easily?*
- Yes
- No
Have there been any significant changes in family structure or social/emotional issues we should be aware of?*
- Yes
- No
Please provide a brief detail.*
List other concerns, special care required, or helpful hints

Eating and Nutritional Issues
Please indicate how much help the camper needs with eating.*
- None
- Partial help needed
- Total help needed (Please provide detail)
Please give detail on the camper's eating needs.*
Does the camper have any special diet, food preparation or feeding technique requirements?*
- Yes
- No
Does the camper have a vegetarian diet?*
- Yes
- No
Please explain in detail anything you would like us to know about this aspect of the camper's diet.
Does the camper have a gluten-free diet?*
- Yes
- No
Is the camper gluten intolerant or have a gluten allergy?
- Gluten Intolerant
- Gluten Allergic
Gluten allergy (e.g. Celiac) is characterized by an immune response to gluten consumption.
Please explain in detail anything you would like us to know about this aspect of the camper's diet.
Does the camper have a blended diet?*
- Yes
- No
Please explain in detail anything you would like us to know about this aspect of the camper's diet.
Please provide any dietary information not covered by the above choices.
Does the camper have any extreme food dislikes?*
- Yes
- No
Please provide more detail.*
Does the camper have a feeding tube?*
- Yes
- No
Please indicate the camper's tube type.*
Please indicate the camper's feeding tube formula.*
Describe feeding schedule including name, type, amount, and times of supplement. (Be sure and send more than enough cans of food & feeding tube supplies)*
Provide the name(s) of other camper(s) the camper would like to eat with.
Bladder & Bowel Care
Indicate how the camper urinates.*
- Sit
- Stand
- Urinal/leg bag
- Diapers
- Catheter (complete section below)
What help does the camper need?*
- Support to sit or stand
- Emptying, changing,cleaning
- Transferring
- Wiping
- Diapers Changed
- Bedpan/Urinal
- None
Please explain typical transfer technique in detail.*
Please list at-home diaper change schedule.*
Please explain bedpan/urinal usage in detail.*
Does the camper require urinary catheterization?*
- Yes
- No
Describe schedule and specifics of bladder/catheterization program or reminder schedule:*
Assistance required.*
- Total
- Partial
- Reminder Only
- None
Please elaborate on what assistance is required.*
Does the camper require assistance with a bowel program?*
- Yes
- No
Detailed description of BM schedule.*
Does the camper have problems with constipation?*
- Yes
- No
How is constipation treated at home?*
Does the camper have an ostomy?*
- Yes
- No
Provide type of ostomy and care.*
*** All campers will be reminded to go to the bathroom or assisted if necessary. Please be sure to send more than enough diapers, undergarments, catheters and ostomy supplies for the week, as well as any other special equipment for your child. We do not have extra supplies.
Speech
Please indicate the camper's speech ability.*
- No Problem Communication
- Understandable
- Non-verbal
Please describe in detail how your child communicates a yes and no. How does your child communicate their needs and interests?
Special ways used to communicate.*
- Sign Language
- Alphabet Board
- Augmented Communication System
- None
Please only send communication devices that the camper uses independently with success with a variety of people. Please label all equipment. Other information about the camper’s communication (unique phrases or gestures to communicate needs, etc.)
Mobility and Special Equiptment
How will the camper move around at camp?*
- Walks
- Manual wheelchair-pushes self
- Manual wheelchair-needs help
- Power wheelchair
- Uses cane
- Uses walker
- Other
Please explain Other camper mobility needs.*
*** We encourage power wheelchair drivers to bring their chairs to maximize independence at camp ONLY if you feel that they are responsible and skilled enough to safely drive with supervision at camp, including driving on uneven terrain, steep inclines, near curbs or in tight spaces with other children. Power wheelchairs can be broken at camp with the rough terrain and unfamiliar ground. Please be aware of this when deciding on the type of chair to send with the camper. Please understand that the Kiwanis cannot be held responsible for broken wheelchairs.
Does the camper require help transferring from bed to wheelchair?*
- Independent
- Needs stand by supervision/slight physical assist
- Needs full physical assist
Does the camper require help transferring from ground to wheelchair or to stand?*
- Independent
- Needs stand by supervision/slight physical assist
- Needs full physical assist
Does the camper require help transferring from wheelchair to toilet?*
- Independent
- Needs stand by supervision/slight physical assist
- Needs full physical assist
Does the camper use a shower chair or other adaptations?*
- Yes
- No
Please elaborate on the equipment the camper uses for showering.*
Will you be packing (and labeling!) any specialized shower equipment? (Note: We will provide shower chairs, benches and handheld showerheads at camp.)*
- Yes
- No
How much assistance does the camper need with sitting without support?*
- Independent
- Needs stand by supervision/slight physical assist
- Needs full physical assist
How much assistance does the camper need with changing positions in bed?*
- Independent
- Needs stand by supervision/slight physical assist
- Needs full physical assist
Give any other information about the camper's mobility and special equipment needs.
AFO/DAFOs
Does your child utilize Ankle Foot Orthosis (AFO/DAFOs)?
- Yes
- No
When does your child utilize their AFO/DAFOs?
When is it appropriate to deviate from this schedule? e.g. If experiencing discomfort, based on level of activity, etc.
Please note we will make every effort to follow the most recent AFO schedule your child is using
Are there any additional details about AFOs/DAFOs you would like us to know?
Please list all mobility equipment, splints or orthotic equipment the camper will bring to camp. Also, please describe schedule of when equipment should be worn at camp (should be based on most current schedule used during summer). *** Be sure to label everything! Equipment Type (arm splint, dafo, etc.) How/when to be worn.
Hygiene
There are only showers at camp. We do adapt with hand-held shower heads and have several shower benches.
Does your child need any special bath adaptations?
- Yes
- No
Please describe these bathing procedures
List any special hygiene aides your child will pack.
Any additional hygiene details?
Dressing
How much help does the camper need with dressing?*
- None (independent)
- Partial help
- Total help
Which side should be dressed first?*
- Either
- Right
- Left
Recommendations*
*** Please bring a spare change of clothes with your camper for every day that you are attending.

*** Do not bring electronics, such as iPods or handheld consoles. Cell phones will be checked in with the barrack's captain.
- I have read these recommendations
Night Care
Can the camper brush his/her own teeth?*
- Yes
- No
Please explain the camper's oral care procedure.*
Is the camper afraid of the dark?*
- Yes
- No
How is this handled at home?*
Has the camper spent a night away from home?*
- Yes
- No
Does the camper sleep with a special toy?*
- Yes (Please label and send)
- No
Should the camper be awakened at night to urinate?*
- Yes
- No
What time at home does the camper go the restroom? Please provide helpful detail.*
Are there other details about your child’s bedtime routine that would help the counselors?*
Name(s) of friends the camper would like to sleep near.

Activities & Other Information
Interest Groups

We cannot guarantee, but will make every effort for every camper to be able to participate with their top two choices for interest groups. Please choose the top three choices for interest groups with "1st" as the camper’s first choice.

**Interest Groups**
Science and Nature - You do science experiments and take nature walks.
Drama and Music - Put on a skit or play a concert.
Cooking - Stir up a masterpiece in the mess hall.
Arts & Crafts - Get your creative side roaring.
Sports - Let's get active!
Technology & Keeping Up with the Casey Bunch - Campers will learn how to set up a blog and or add posts and pictures to the Kiwanis Camp Casey Facebook Page.
Interest Group First Choice
Please do not select the same choice multiple times.
Interest Group Second Choice
Please do not select the same choice multiple times.
Interest Group Third Choice
Please do not select the same choice multiple times.
What are the camper's main interests and leisure activities?
We will be preparing a Camp Casey Directory to include each camper's name, address, phone, and birthday and email address. This directory will only be used by fellow campers, counselors and Kiwanis staff. Please indicate your preference for inclusion in the directory.*
- Yes, include the camper's information
- No, do not include the camper's information
May we have permission to use photographs of the camper for publicity purposes by the North Central Kiwanis Club or the news media?*
- Yes
- No
T-shirts*
Each camper receives a free Camp Casey T-shirt. Indicate what size the camper needs:
Traveling to Camp
Kiwanis Camp Casey will take place this year at a public park in Seattle. Campers will attend at least one day, and possibly two depending on interest and age group over the week of July 26-30, 2021.

We will be requiring that campers are dropped off between 8:30am and 9am and picked up the same day at 4pm. If you anticipate any hardships associated with the transport model, please indicate below.
Travel to camp*
Since we will be holding a modified version of camp this year, we will be requiring that campers are dropped off each day that they are attending at 9am, and picked up at 4pm in Seattle. If you anticipate that transportation to Seattle, will be difficult please indicate below. We will reach out to all families which indicate that they need assistance upon completion of application.
- I can drive my child to/from Seattle
- I am interested in carpooling options
- I am able to drive my child, but would require financial assistance
Name and relationship of person dropping camper off between 8:30-9am*
*** We will be checking identification of those picking up and dropping off campers.
Name and relationship of person picking up camper at 4pm.*
*** We will be checking identification of those picking up and dropping off campers.
Counselors and nurses want the opportunity to learn your child's name before camp. Please provide a current picture. In addition, add any pictures that would help us provide care for your child. Examples would be splint or bedtime positioning.
Drop files here or

Accepted file types: jpg, gif, png, jpeg, zip, pdf, Max. file size: 100 MB.
Please feel free to provide us with any information you feel will help us care for the camper at camp.
In addition, if your application is very complicated or if you have routines or equipment that requires detailed knowledge, please contact us to arrange for a counselor or nurse home visit.
We love to hear from our camper's parents!

Please read and agree to the forms below.
Please read and agree to the forms below.
Please read Camp Casey Camper Code of Conduct. (link below)*
- I have reviewed the Camper Code Of Conduct with the camper. We know what is expected and agree to the guidelines specified.
I acknowledge that I will electronically sign the Release Form before coming to camp.*
- Link to e-sign will come later
Legal Acknowledgement:*
- I have completely and honestly read and filled out the camper application and give permission for the camper to attend Kiwanis Camp Casey.
Name of person completing this application:*
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