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. Camp fills 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. See the last page of the registration form for more information about camp.
Payment
Adults (ages 16+): $125 per person Children (ages 5-15) $75 per person Children (4 and under) Free Minimum $25 (nonrefundable) per person deposit is requested with this registration. Remaining balance due one month prior to the retreat. Refunds 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)


REMINDERS:
  • A minimum $25 (nonrefundable) per person deposit is requested with this application. Remaining balance is due one month prior to camp to the retreat weekend and is nonrefundable except in the case of a medical emergency. If you are registering less than one month prior to camp, the entire fee is due at this time. You can pay your camper fees by mailing a check payable to Stroke Camp. Once we have received your registration form/deposit, we will email or mail you (whichever communication method you indicated on page 1 of this form) a confirmed email/postcard.
  • Camp Check-in is between 1:30pm and 3:30pm on Friday! Please make arrangements with you schedule so that you are able to join us for the start of the weekend.
GENERAL INFORMATION:What do we do at camp? Crafts, games, educational sessions, resources, pampering, friendships, good food, hiking/walking, discussion groups, informal chat with experts, Wii, entertainment, relaxing, and more!

NOTE: Outdoor activities will vary by retreat center location and time of the 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. Visit www.strokecamp.org for more information about camp!

Room Assignments: Rooms are hotel style with a private bathroom. Survivors attending without a caregiver may be paired with another survivor of the same gender when appropriate. Handicap rooms will be assigned according to availability and need. Retreat & Refresh Stroke Camp (RRSC) does its best to review registrations. It is the responsibility of the registrant to submit a complete and accurate registration. RRSC reserves the right to reject or revoke a registration that it deems is inaccurate, incomplete, or for which registrant would not be suitable for RRSC’s program(s), as determined in RRSC’s sole and absolute discretion.
Retreat and Refresh
Retreat and Refresh
Questions?: Contact the United Stroke Alliance Office by calling (309) 688-5450 OR email registration@strokecamp.org