Retreat & Refresh Stroke Camp
Sponsored by: VCU Health
Airfield Conference Center
Wakefield, VA
September 8-10, 2017

Camper Registration Form
We're glad you're interested in Stroke Camp! 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
# of Adults (ages 16+) Attending X $ 125 per person
# of Children (ages 5-15) Attending X $ 75
# of Children 4 and under Attending X free
*Total fees: $
Minus $25 deposit per person, due with this application: - $
Remaining balance due one month before camp:  $

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.

 

SURVIVOR INFORMATION

*Name:
*Address:
*City:
*State:* Zip
*Name Badge Should Read:
*Phone:
*E-Mail:
Birth date:
*Age:
*Shirt Size:
*Preferred method of communication for pre-camp information (select one) Email Mail

 

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 or night.
             
*My caregiver will be with me Yes    No

 

If no, phone # where caregiver can be reached 

 

CAREGIVER INFORMATION:

Name:
Address:
City:
State: Zip
Name Badge Should Read:
Phone:
E-Mail:
Birth date: Age:
Relationship to survivor:
Shirt Size:
 Preferred method of communication for pre-camp information (select one) Email Mail

Additional Family Members Who Are Attending Camp:

Name: Age: Sex: Shirt Size

 

Name: Age: Sex: Shirt Size


**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

 

*Month/Year of stroke                 Was the stroke a blockage    bleed?

 

Which side of your body was affected (if any)  Right           Left

*Physical limitations (if any)

 

None Arm Weakness Leg Weakness Standing Transferring Walking

Other limitations (please list in box below)

 

*Communication status:

 

None Aphasia Apraxia Swallowing problems

 

*Assistance Needed (assistance with activities of daily living must be provided by the survivor's caregiver):

 

None Transferring Walking Bathing Toileting Dressing Eating Taking medications

Other (please list in box below)

 

*Please list any medical equipment necessary for this camper you will be bringing:

 

None Walker Cane Wheelchair Raised toilet seat Shower chair/bench

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 No

If yes, please describe the special diet/allergy in the box below (include names of all family members who require the diet).
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.

 

Is 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?

 

*What still challenges you?

 

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.