Camper Information Has the camper attended Camp Bloomfield before? * Required Who is this application for? * Required Sighted sibling terms (required) I understand that sighted sibling spots are limited, cost $300, and are not guaranteed. Placement depends on available space within the appropriate age group and gender identity.
Name * Required
First
Last
Date of Birth How much can your camper see? * Required Additional disabilities/support needs (in addition to blindness/visual impairment) * Required What formats/supports does your camper use? (Check all that apply) * Required Does your camper need staff support navigating new environments? * Required
Parent/Guardian Name * Required
First
Last
Email: * Required Please provide the best email address for event communication.
Parent/Guardian Address * Required
Parent/Guardian 2 (alternate adult contact) We strongly recommend adding a second parent/guardian or alternate adult contact in case we can’t reach you. Check here to fill out information for a second parent/guardian.
Parent/Guardian 2 Name * Required
First
Last
Parent/Guardian 2 Email * Required Parent/Guardian 2 Address * Required
Same as Parent/Guardian 1
PHYSICAL: Does your camper use any of the following? * Required What support does your camper need to participate safely? * Required
INDEPENDENCE: Does your camper need assistance with any of the following? * 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 Does your camper have a history of severe allergic reaction (anaphylaxis) or require an EpiPen? * Required What triggers the camper's severe allergy risk? (Check all that apply) * Required Does your camper have any of the following? (Check all that apply) * Required Please describe / provide further information: * Required
Does your camper use a rescue inhaler (e.g., albuterol)? * Required In the past 12 months, has your camper visited the ER or urgent care for asthma or breathing problems? * Required Are your camper’s asthma symptoms triggered by any activities or environments? * Required Are the camper's seizures controlled with medication? * Required Seizures: Typical length + What helps after / Precautions * Required
Diabetes type: * Required Does the camper use insulin? * Required How is the camper's blood sugar typically monitored? * Required Does the camper 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, has the camper had any of the following? (Check all that apply) * Required At camp, diabetes management will require: * Required Does the camper have glucagon available (for severe low blood sugar) * Required If yes, what type? * Required Does exercise usually cause your camper's blood sugar to drop too low? * Required Does your camper have a history of blood sugar highs or lows that you’re aware of, even if they don’t have diabetes? * Required What triggers can cause your camper’s blood sugar to go very high or very low? (Check all that apply) * Required
Does your camper take any medications during camp (including OTC/as-needed)? * Required Medication verification consent: * Required Any meds need refrigeration? * Required How are meds managed at home? * Required Does your camper have emergency/rescue medication they may need to access quickly at camp? * Required Is your camper approved (parent/guardian + physician) to carry emergency/rescue medication independently at camp?” * Required Policy: 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.
Does your camper have an IEP or 504 Plan? * Required What supports/accommodations are most important for camp? * Required
Willing to share relevant sections via CampDoc in April? * Required
Recent Health Events Has your camper 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 your camper? * Required Camp includes outdoor activities at high elevation, hills and frequent walking, 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
Does the camper have challenges with any of the following: * Required Triggers to avoid * Required
Strategies that work best * Required
Safety concerns we should know * Required
Camp Logistics How will the camper be arriving at Camp Bloomfield? (Please select one option): * Required What is the camper's swimming ability? * Required Does your camper need a bottom bunk? * Required
Counselor In Training Volunteer Opportunity
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
Consent * Required The undersigned parent/guardian represents to Wayfinder Family Services that the minor named in this application is in his and/or her legal custody and control; and that the undersigned desires said minor to participate in the programs of Wayfinder Family Services, and that for purposes of said participation the undersigned agrees, authorizes and states as follows:
I have read and agree to the AUTHORIZATION FOR TREATMENT OF ADULT CONSENT, RELEASE, AND COVENANT:
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.
