Camper Registration Form
We’re glad you’re interested in Stroke Camp!
Please fill out this registration form in its ENTIRETY and submit ASAP!
**SHIRT SIZES ARE NOT GUARNTEED FOR REGISTRAITONS RECEIVED LESS THAN THREE WEEKS PRIOR TO CAMP!
Payment
Adults (ages 16+) $150/person
Children (ages 5-15) $75/person
Children (4 & under) Free

Minimum $50 (nonrefundable) PER PERSON deposit is requested with this form. Remaining balance due one month prior to the retreat –refunds of balance (not deposit) are made ONLY in the case of a medical emergency!
ATTENDANCE
# of Adults:
# of Children:
# of Children (4-Under):
TOTALS
Total fees due:
Minus deposit per person due with this registration:
Remaining balance due one month before camp:
BASIC SURVIVOR INFORMATION
Name:
Address:
City: State:
Zip:
Phone:
Email:
Birth Date: / /
Age:
Name Badge Should Read:
Shirt Size (specify one): S M L XL 2XL 3XL
Preferred method of communication for pre-camp informationEmail Mail (This is how you will receive your info packet before camp) 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, please provide a phone # where caregiver can be reached in case of emergency:
CAREGIVER BASIC INFORMATION
Name:
Address:
City: State:
Zip:
Phone:
Email:
Birth Date: / /
Age:
Name Badge Should Read:
Shirt Size (specify one): S M L XL 2XL 3XL
Preferred method of communication for pre-camp informationEmail Mail (This is how you will receive your info packet before camp)
ADDITIONAL FAMILY INFORMATION
Name:
Age:
Shirt Size (specify one): S M L XL 2XL 3XL
Name:
Age:
Shirt Size (specify one): S M L XL 2XL 3XL
Do any FAMILY MEMBERS require any special diet beyond heart healthy, diabetic friendly, or have any food allergies?YES NO
If YES, please describe the special diet/allergy (include names):

HELPFUL SURVIVOR INFORMATION
REMEMBER: The more info you provide, the more accurate we can be in assigning rooms and knowing how to assist you.
Physical Limitations: None Arm Weakness Leg Weakness Standing Transferring Walking other:
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:

Medical Equipment (Please list any medical equipment necessary that YOU will be bringing (We have a very limited supply)):
Cane (Used how often?):
Walker (Used how often?):
Wheelchair (Used how often?):
Raised Toilet Seat Shower Chair/Bench Other:
ADDITIONAL HELPFUL SURVIVOR INFORMATION
Month/Year of Stroke: /

Type of stroke: Clot/Blockage Bleed/Hemorrhage

Which side of your body was affected: Right Left Both None

How did you hear about Stroke Camp?:

Does the survivor require a special diet beyond hearth healthy, diabetic friendly or have any food allergies?YES NO
If YES, please describe the special diet/allergy:

What do you see as your most successful accomplishments since your stroke?:

What still challenges you?:

Is there any further information that may be helpful for us in better understanding the stroke survivor and his/her needs at camp?:

Is there a particular topic you would like to learn about or a presenter you would like to hear from during the education session at camp?:
Helpful CAREGIVER INFORMATION
Please list any special needs or physical limitation the CAREGIVER (If accompanying the survivor to camp) has that we need to be aware of prior to camp:

Does the CAREGIVER require any special diet beyond heart healthy, diabetic friendly, or have any food allergies?YES NO
If YES, please describe the special diet/allergy:
**SPECIAL DIETS -Please note: 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.

**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.
NEXT STEP CHECKLIST AND INFORMATION
NOW:
Submit:
· Your Registration Form
· Deposit/Full Payment

To:
United Stroke Alliance
2000 W. Pioneer Pkwy, Ste. 16
Peoria, IL 61615


1 month prior to camp:
Pay Balance- if you paid only the deposit at the time of registration, please mail your remaining balance due to the United Stroke Alliance office (address above).

Ways you can pay for your registration:
OFFLINE:
Cash/Check (mail to address above. Checks can be made out to Retreat and Refresh Stroke Camp. Please be sure to specify exactly who and which camp the payment is for!!

ONLINE
www.strokecamp.org (Pay Camp Fees)


Approximately 1 or 2 weeks prior to camp:
We will email or mail you (whichever communication method you indicated on page 1 of this form) a packet of information that includes :
  • The Weekend Schedule
  • Camp & Facility Information
  • Packing Check Guide
  • Directions to camp
  • Health History Form

Day of camp:
Packing-Make sure you have packed everything you need. Please refer to the“Packing Check Guide” we mailed/emailed you if you need guidance. Don’t forget any adaptive equipment that is necessary for you to perform your activ-ities of daily living!

Health History Form-Unless you have already mailed it to us, bring the COMPLETED health history form to check-in at camp. Be sure to include a copy of your medication list. We need this form for ALL participants: survivors, caregivers, and family members/friends. The form is available on the Camp Date/Registration page of www.strokecamp.org.


(if you have changed your mind and no longer plan to attend Stroke Camp, please call our offices immediately to notify us as many of our camps have a wait list of participants. (309) 688-5450)


CAMP INFORMATION AND REMINDERS:

  • What do we do at camp?: Crafts, games, education sessions, resources, pampering, friendships, good food, hiking/walking, discussion groups, informal chat with experts, entertainment, relaxation and more! NOTE: Outdoor activities will vary by retreat center location and time of year, but may include fishing, boating, rock wall climbing, and swimming. The entire weekend is carefully planned for stroke survivors, caregivers, and family members. Activities are modified so that everyone can participate. Volunteers will support and assist you throughout the weekend however, they are NOT expected to assist with activities of daily living! Visit www.strokecamp.org for more information about camp or find us on Facebook!
  • What time does camp start?: Camp check-in is between 1:30pm and 3:30pm on Friday for most camps! Please make arrangements with your schedule so that you are able to join us for the start of the weekend. Camp will end approximately around 1:00pm on Sunday.
  • When do I pay my fee/Refund Policy?: A minimum $50 (nonrefundable) per person deposit requested with this registration form. Remaining balance is due ONE month before camp and refunds of balance are made ONLY in the case of a medical emergency! Payment without a registration form will NOT guarantee a spot!!!
  • What are rooms like?: There are multiple twin beds in each room. Survivors attending with family members will be assigned together in rooms with a nearby bathroom. Room dividers will separate the sleeping areas when rooms do need to be shared with fellow campers. Survivors attending without a caregiver may be paried with another survivor of the same gender when appropriate. We have limited supply of adaptive equipment to help but be sure to bring everything you’ll need!
  • Pet Policy?: Please leave your furry friends at home. Only certified SERVICE animals are an exception. If you are planning on bringing a SERVICE animal, please let Stroke Camp know ASAP so that we can notify the facility so that they can make proper arrangements and bring certifications.
  • Transportation to Camp?: Unfortunately Stroke Camp does not have the ability to provide transportation to and from camp. It is the responsibility of the camper to arrange transportation with a willing caregiver or by carpooling or by public transportation if available.
If you have any more questions, FAQs can be found on the FAQ page of www.strokecamp.org!
Or contact the United Stroke Alliance office at registration@strokecamp.org or 309-688-5450.

**MAKE SURE TO ADD registration@strokecamp.org TO YOUR EMAIL ADDRESS BOOKS TO ENSURE YOU GET ALL IMPORTANT INFO!!
Retreat and Refresh
Retreat and Refresh
Questions?: Contact the United Stroke Alliance Office by calling (309) 688-5450 OR email registration@strokecamp.org