Camper Information Have you attended Camp Bloomfield before? * Required Name * Required
First
Last
Date of Birth: How much can you see? * Required Additional disabilities/support needs (in addition to blindness/visual impairment) * Required What formats/supports do you use? (Check all that apply) * Required Do you need staff support navigating new environments? * Required
Contact Information Email * Required Please provide the best email address for event communication.
Address * Required
PHYSICAL: Do you use any of the following? (Check all that apply) * Required What support do you need to participate safely? * Required
Camp includes hills and longer walks. Which option best fits you? * Required INDEPENDENCE: Do you need assistance with any of the following? (Check all that apply) * Required Please briefly describe what support is needed and what works best. * Required
DIETARY NEEDS: (check all that apply) * Required We accommodate allergies and medically necessary dietary needs. We are not able to accommodate food preferences or picky eating.
ALLERGIES: (check all that apply) * Required Do you have a history of severe allergic reaction (anaphylaxis) or require an EpiPen? * Required What triggers your severe allergy risk? (Check all that apply) * Required Do you have any of the following? (Check all that apply) * Required Please Describe / provide further information: * Required
Do you use a rescue inhaler (e.g., albuterol)? * Required In the past 12 months, have you visited the ER or urgent care for asthma or breathing problems? * Required Are your asthma symptoms triggered by any activities or environments? * Required Are your seizures controlled with medication? * Required Seizures: Typical length + What helps after / Precautions * Required
Diabetes type * Required Do you use insulin? * Required How is your blood sugar typically monitored? * Required Do you use a correction or sliding-scale insulin plan? * Required If requested, are you able to share the written plan through CampDoc in April? * Required In the past 12 months, have you had any of the following? (Check all that apply) * Required At camp, diabetes management will require: * Required Do you have glucagon available (for severe low blood sugar) * Required If yes, what type? * Required Does exercise usually cause your blood sugar to drop too low? * Required Do you have a history of blood sugar highs or lows that you’re aware of, even if you don’t have diabetes? * Required What triggers can cause your blood sugar to go very high or very low? (Check all that apply) * Required
Will you need to take medication during camp (including OTC/as-needed)? * Required How are your medications managed at home most days? * Required Which of the following can you do reliably on your own? (Check all that apply) * Required In the past 30 days, how often have you missed a dose or taken it late? * Required Do you take any as-needed medications—meaning medications you take only when needed (for example: pain medicine, anxiety medication, sleep aids, nausea medicine, or an inhaler)? * Required Do you know when to take them and your safe limits (max dose/day) without help? * Required Do any medications need refrigeration? * Required Camp has a busy schedule and a different routine. What help will you need to take your medications? * Required Do you have emergency/rescue medication you may need to access quickly at camp? * Required Are you able and approved to carry emergency/rescue medication independently at camp? * Required Medication safety agreement * Required I understand that approval to self-manage medications at camp is not guaranteed. I agree to follow the medication plan determined by Camp Bloomfield’s health team during review and intake (including reminders, staff support, and/or physician documentation if requested).
If a camper is not approved to carry emergency/rescue medication independently, their assigned counselor will carry it and ensure it’s available when needed.
Recent Health Events Have you had any major health changes, surgeries, or hospitalizations in the past 12 months? * Required Physician guidance (if needed): If our team requests it, are you able to provide a brief physician note confirming the camp environment is appropriate for you? * Required Camp includes outdoor activities at high elevation, hills and longer walking distances, and seasonal dust/pollen. We don’t request physician notes for everyone—only in specific situations where it helps us confirm camp is safe and set up the right supports.
Please share any concerns or context you’d like us to know * Required
Do you have challenges with any of the following? (Check all that apply) * Required Triggers to avoid * Required
Strategies that work best * Required
Safety concerns * Required
Camp Logistics How will you be arriving at Camp Bloomfield? * Required What is your swimming ability? * Required Do you need a bottom bunk? * Required
Ethnicity * Required
Releases and Disclosures COVID Information * Required While participating in events held or sponsored by Wayfinder Family Services, consistent with CDC guidelines, participants are encouraged to practice hand hygiene, “social distancing” and wear face coverings to reduce the risks of exposure to COVID-19. Because COVID-19 is known to be contagious and is spread mainly from person-to-person contact, Wayfinder Family Services has put in place preventative measures to reduce the spread of COVID-19. However, Wayfinder Family Services cannot guarantee that its participants, volunteers, partners, or others in attendance will not encounter COVID-19.
I acknowledge that my participation (or my child’s) in Wayfinder Family Services program is at my own risk.
ACTIVITY PERMISSION AND RELEASE * Required I hereby grant participant named above permission to participate in all activities offered by or through Wayfinder Family Services, with the exception of those activities indicated above. The undersigned parent, guardian, or custodian of the above named participant hereby joins in the foregoing Activity Opt-Out Form and hereby stipulates and agrees to save and hold harmless, indemnify, and forever defend Wayfinder Family Services, their directors, officers, agents, employees, and volunteers from and against any claims, actions, demands, expenses, liabilities (including reasonable attorney fees) for negligence as a result of said participant’s participation in the activities of Wayfinder Family Services and his or her use of the property, animals, and facilities. I, on behalf of said participant, further agree not to sue Wayfinder Family Services, its directors, officers, agents, employees, and volunteers as a result of any injury that said minor suffers from negligence in connection with his/her participation in the activities of Wayfinder Family Services.
I have read and agree to the ACTIVITY PERMISSION AND RELEASE
AUTHORIZATION FOR TREATMENT / CONSENT, RELEASE, AND COVENANT * Required Medical Authorization:
I, the undersigned participant, or, if applicable, the parent/guardian of the minor participant named below, wish for the participant to take part in the programs of Wayfinder Family Services and have read and agree to the AUTHORIZATION FOR TREATMENT OF ADULT CONSENT, RELEASE, AND COVENANT
PARTICIPANT/PARENT/GUARDIAN MEDIATION AND ARBITRATION AGREEMENT: * Required This is an Agreement to mediate and arbitrate all unresolved disputes arising from the educational, recreational, special education school, and residential services between the undersigned camper and/or their legal guardian and the Wayfinder Family Services.
I, the undersigned participant, or, if applicable, the parent/guardian of the minor participant named below, wish for the participant to take part in the programs of Wayfinder Family Services and have read and agree to the PARTICIPANT/PARENT/GUARDIAN MEDIATION AND ARBITRATION AGREEMENT
Media Release * Required Permission is hereby given to WAYFINDER FAMILY SERVICES® to use audio, video recordings, photographic and electronically created images of the camper noted in this application for public view, including publications, websites or social media sites. Usage of any images or audio is without compensation to said person or to the undersigned on his/her behalf, or individuality.
I have read and agree to the MEDIA RELEASE
Special Event Waiver * Required In consideration of the acceptance of my family’s participation in the following activity listed on this form, I, the undersigned, intending to be legally bound, do hereby for myself and my family (including heirs, executors, administrators and assigns) forever waive, release and discharge any and all rights, claims and actions for damages that we may have, or that may hereafter accrue to us against WAYFINDER FAMILY SERVICES, including all of its officers, directors, members and volunteers.
I have read this waiver and am in agreement with its contents.
Hold Harmless * Required In consideration of the acceptance of my family’s participation in the activity listed on this form, I, on behalf of myself and my family, agree if any claim for personal injury or wrongful death is commenced against WAYFINDER FAMILY SERVICES (including its officers, directors, members and/or volunteers), we will defend indemnify and hold harmless WAYFINDER FAMILY SERVICES, from any and all claims or causes of action for personal injuries, property damage or wrongful death that hereafter accrue, arise out of, result from, or are caused directly or indirectly by my family’s participation in this activity.
I agree to the privacy policy.I have read the Hold Harmless Release and am in agreement with its contents.
Signature Confirmation * Required By entering my full name below, I confirm that I have read, understood, and agree to the terms outlined in the Waiver & Release of Liability above. I understand that typing my name serves as my digital signature and legally binds me to the terms of this agreement.
