Minimum $25.00 (nonrefundable) per person deposit is requested with this application. Remaining balance due one month prior to the retreat-nonrefundable except in the case of an emergency.
We encourage survivors to bring a caregiver with them. If you do not
have a caregiver to attend with you please note below a person who will be
willing to pick you up from camp or the hospital in case of an emergency day
will be with me Yes No
no, phone # where caregiver can be
Additional Family Members Who Are Attending Camp:
S M L XL 2XL 3XL
Survivor Miscellaneous Information
of stroke Was the stroke a
side of your body was affected (if any) Right Left
*Physical limitations (if any)
Other limitations (please list in box below)
Needed (assistance with activities of daily living must be provided by the survivor's caregiver):
Other (please list in box below)
list any medical equipment necessary for this camper you will be bringing:
Raised toilet seat
Other:(please list in box below)
Will you or your family require a special diet beyond heart healthy diabetic friendly, or have any food allergies? Yes
If yes, please
describe the special diet/allergy in the box below (include names of all family members who require the
While our best efforts will be made to accommodate your request, we suggest you bring snacks
and/or food to supplement your diet if you are concerned about having food available that you can eat.
there any further information that may be helpful in better understanding the
stroke survivor and his/her needs at camp? (please describe in box below)
Please list any special needs or physical limitations the caregiver (if accompanying the survivor to
camp) has that we need to be aware of prior to camp.
*How did you hear about camp?
*What do you see
as your most successful accomplishments since your stroke?
Is there a particular topic you would like to learn about or presenter you would like to hear from
during the education session at camp?