Retreat & Refresh Stroke Camp
Sponsored by: Friends & Volunteers of Retreat & Refresh Stroke Camp
Lutheran Outdoor Ministries Center
August 3-6, 2017
Camper Registration Form
We're glad you're interested in Stroke Camp!
This 4 day family focus camp has programing designed specifically for youth who have a parent who has had a stroke, in addition to programming for survivors and caregivers.
Please fill out this registration form in its entirety and submit as soon as possible. Camps fill up fast and rooms are assigned on a first come, first served basis.
Shirt sizes are not guaranteed for registrations received less than three weeks prior to camp. You will receive more information about camp once you submit this form.
* Required Fields
Please complete all of the requested information in each section
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:
**Please call our office if the additional family members live separately from the survivor and/or caregiver so that we can get their contact information.**
Your name, address, phone number, email address, and stroke date will be distributed to all in attendance at camp. All other information obtained for Stroke Camp is solely used in the event of a medical emergency and will be kept secured and confidential.
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
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?
If you have any questions, please feel free to call us. 309-688-5450.