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SERTOMA
CAMP ENDEAVOR
Camp Endeavor 2023
June 25th - July 1st
Waitlist Application
Child's First Name:
Child's Last Name:
The Camper is:
Deaf
Hard-of-Hearing
CODA
Sibling of D/HH
Camper Information:
Camper Date of Birth:
Camper Gender
Camper Age at Time of Camp:
Camper Shirt Size
Name of Current School:
Camper currently lives with:
Current Grade:
If other, who?
Height
Weight
Assistive devices used:
Hearing Aids
Cochlear Implant(s)
Other
None
Medical History:
ADD
ADHD
ALLERGY TO ENVIRONMENT
ALLERGY TO FOOD
ALLERGY TO INSECT STINGS
ALLERGY TO MEDICATION
ASTHMA
HIGH/LOW BLOOD PRESSURE
BEDWETTING
BROKEN BONE
CONSTIPATION
DIABETES
DIARRHEA
EAR INFECTIONS
EATING DISORDER
EPILEPSY
HEADACHES
GLASSES/CONTACTS
HEART PROBLEMS
LUNG PROBLEMS
PSYCHIATRIC COUNSELING
SKIN PROBLEMS
OTHER
NONE
Does your camper need assistance with:
Restroom
Clothing
Bathing
Eating
None
Has the camper ever attended Camp Endeavor?
What is your camper's swimming capability?
Camper's Preferred Mode(s) of Communication:
American Sign Language
Spoken English
Gestures
Other
If other, what?
Please explain any medical history boxes checked:
Please list any physical activity restrictions perscribed by a medical professional:
Please list any perscribed medications and their perpose:
Any additional disabillities, comments or things to know about your camper?
My child may participate in any camp-sponsored field trips away from Sertoma Camp Endeavor premises and be transported by vehicle driven by designated licensed staff.
Yes
No
Parent/Guardian Information:
First Name:
Last Name:
Email:
Phone Number:
Adress:
What is your relationship to the camper?
If other, what?
What type of contact is this?
Call
Text
VP
City, State, Zip Code
Emergency Contact (please make it a different person from the parent guardian listed above)
First Name:
Last Name:
Email:
Phone Number:
Adress:
What is your relationship to the camper?
If other, what?
What type of contact is this?
Call
Text
VP
City, State, Zip Code
Please submit camper physical here. Camper physicals are due by Drop off on Sunday, June 25th. If you have any issues with uploading physicals please email them to
campendeavortech@gmail.com
Upload Camper Physical
Upload supported file (Max 15MB)
Camper Tuition of $250.00 is due at the time of application. Payment will be completed on the next page.
Pay Camper Tuition
Thank you for your applicaiton!
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