PLEASE FILL OUT COMPLETELY: Applications must be fully completed before Camper is considered. 

Please indicate session preference: Campers are assigned to sessions by Camp Administrative staff based on assessment and session availability. We will make every effort to place the camper in the session of choice. Please indicate below if Camper can only attend chosen session. 

Camper Personal, Financial and Insurance Information


Camper:
Parent or Guardian (1)
Telephone:
Parent or Guardian (2)
Telephone:

Emergency Contact: (Must be other than parents and guardians listed above)

Emergency Contact
Telephone:

Camper Personal Information:

Physician Information

Insurance Information:

Coverage for illnesses or injury while participating in programs at Camp Dream is the responsibility of the parent or guardian of the participating Camper. Please provide medical/hospital insurance coverage information below. 

Camper Care

Nature of Condition

Functional Description

Allergies

Special Equipment

IMPORTANT: Camper should bring any of the items that they normally use.

Mobility

If a lift is used and/or the camper is over 200 pounds and cannot assist with transfers, a lift must be brought to camp.

Eating

Drinking



grams of carbohydrates
grams of carbohydrates
grams of carbohydrates
mg/dL 
 mg/dL above correction target
Special Note: Please bring extra supplies and Glucagon Pen; Emergency Kit for Low Blood Sugar.



If camper wears diapers or pull ups, please be sure to send enough for the entire session.

Sleeping

IMPORTANT – PLEASE READ: Individual room doors are not locked at any time during the camping session. Campers who may wander from their room during the night are not eligible for camp. If this behavior occurs while at camp, the camper may be sent home. 
Seizures

Communication/Socialization

Behavior

Temper:
Fears/worries:
Wandering:
Group
Other:

Additional Information


Medications and Special Medical Instructions

SPECIAL NOTE: Inform the Camp Nurse immediately if you are exposed to any communicable disease (chicken pox, mumps, measles, flu etc) within one month of the camping session.
Over the Counter Medications


List all medications, dosages, and times medication is to be taken. Medications will be administered exactly as written below. Please be accurate and complete. You must provide all medications for your child. All medication must arrive in original container with the prescription label intact and legible. If no medications are taken, please write “none” for the name of the medication. 

Please notify the Camp Nurse if more than ten (10) medications are to be listed.

Recent Medical Conditions or Treatments

Affirmations and Consents

I hereby affirm that all information given is true and complete. I warrant that all information entered within this application is complete and accurate. 



Acceptance Conditions

Camp Dream/ Camp Dream Foundation (CDF) reserves the right to refuse to provide services to any individual when the camp staff determines that the Camper cannot be provided adequate support. These decisions are made on an individual basis by camp administrative staff. Parents and/or care providers will be promptly notified in the event of any serious injury or illness requiring more than basic first aid, or in the case of any significant incident or behavioral issue. 

Medical Care, Medications and Procedures 

I give permission for medical staff to administer prescribed and over-the-counter medications and procedures, including but not limited to the treatment of constipation and the common cold, for Camper named above

In the event of a need for emergency medical care:

 I, or the undersigned, parent/ guardian of above named Camper, a minor or conserved adult, do hereby authorize any adult person into whose care said minor has been entrusted by a representative of CDF, a nonprofit corporation, to act as my agent to consent to any x-ray examination, anesthetic, medical or surgical or dental diagnosis or treatment, and hospital care which is recommend by, and to be rendered under the general or special supervision of, any licensed physician and surgeon or dentist, whether such diagnosis and treatment is rendered at the doctor’s office or at a hospital.

I understand that this authorization is given in advance of any specific diagnostic, treatment or hospital care being required, but is given to provide authority to the above-named agent to give consent to any and all such diagnosis, treatment or hospital care that a licensed doctor or dentist recommends. This authorization shall remain in effect for the duration of time that the above named minor or conserved adult is a resident at any Camp Dream camping session. 

Emergency Release of Camper

In the event that the above named camper must leave camp prior to the end of the camping session for any reason (including, but not limited to, inclement weather posing potential safety risks, staff illness or camper behavioral issues) and I, (the parent, legal guardian or conservator) are unable to be contacted, permission is given to CDF to release the camper to the persons listed within this application as the emergency contact. I acknowledge that the person listed as emergency contact must be able to present proper identification to the Camp Director. Emergency contacts must be at least 18 years of age. 


Release of Information

To the extent permitted by law, I give consent to CDF to release any necessary information or documentation to agencies/organizations on behalf of the above named in response to an appropriate request thereof and appropriate assurances of privacy and confidentiality from the agency or organization requesting the information.

Personal Property

 I recognize that CDF does not accept any responsibility for the care and safekeeping of clothing and other personal property of the above named camper. I understand that any items the Camper brings to camp (including, but not limited to, cameras, athletic equipment or expensive clothing) are the responsibility of me (the parent, legal guardian or conservator) ,and CDF is not responsible for lost items.

Horseback Riding

I acknowledge the risks and potential for risks of horseback riding. However, I feel that the possible benefits to myself/my son/my daughter/my ward are greater than the risk assumed. In consideration of myself/my son/my daughter/my ward being allowed to participate in the Horeseback Riding&program, I, individually and on behalf of my son/my daughter/my ward hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, and those of my son/my daughter/my ward waive and release forever all claims for damages against CDF, Camp Grace and contracted Horse Handlers; to include their Board of Directors, Instructors, Volunteers, and Employees for any or all injuries and/or losses I/my son/my daughter/my ward may sustain while participating in Horseback Riding program during camp, except when caused by intentional misconduct or gross negligence by CDF, Camp Grace and contracted Horse Handlers; to include their Board of Directors, Instructors, Volunteers, and Employees .

Motorcycle Riding

 I acknowledge the risks and potential for risks of motorcycle riding. However, I feel that the possible benefits to myself/my son/my daughter/my ward are greater than the risk assumed. In consideration of myself/my son/my daughter/my ward being allowed to participate in the Horeseback Riding program, I, individually and on behalf of myself/my son/my daughter/my ward hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, and those of myself/my son/my daughter/my ward waive and release forever all claims for damages against CDF, Camp Grace and volunteer Motorcycle Drivers; to include their Board of Directors, Instructors, Volunteers, and Employees for any or all injuries and/or losses I/my son/my daughter/my ward may sustain while participating in the Motorcycle Riding program during camp except when caused by intentional misconduct or gross negligence by CDF, Camp Grace and volunteer Motorcycle Drivers; to include their Board of Directors, Instructors, Volunteers, and Employees.
Photographs, Likenesses, Images and Recordings

 I give consent to CDF to photograph and/or create video or audio recordings of myself/my son/my daughter/my ward, without limitation and to use such photographs, videos or audios and Camper's name, likeness and voice and/or any related stories (“Likeness”) in connections with any of the work, programs, projects, fundraising or other endeavors of CDF in any and all media, including without limitation, electronic or digital media, whether known or unknown at this time, forever worldwide and without restriction, without consideration or compensation of any kind. I release, discharge and hold harmless CDF and its affiliates, including, without limitation, its Officers, Directors, Shareholders, Employees, Agents and Contractors (“Released Parties”) from any and all claims and demands arising out of or in connection with the use of my/my son/my daughter/my wardLikeness, Including slander, libel, invasion of privacy or publicity, and/or copyright infringement (“Release”). This Release applies to me/my son/my daughter/my ward and my heirs, legal representatives and assigns and I do hereby release, discharge and hold harmless the Released Parties from any claim or demand whatsoever arising out of or in connection with such use. I hereby represent that I have the authority to grant the rights referenced herein.
By signing and dating below, I give consent and acknowledge all of the above stated policies.

Camping Session Fees

Camping session fees are $500 per camper and are due prior to assignment of the camper to a camping session. 

Campership

We encourage you to identify and obtain campership funding from your local community. Sources of sponsorship could include civic organizations such as Lions, Jaycees, Elks, Moose, Rotary, Sororities, and others. You may also apply for a micro-grant from your local EMC, Wal-mart or other retailer. Families with financial hardships may qualify for a partial or total campership from the Camp Dream Foundation. Please, pay as much as you can toward the camping fee and help us raise money for your camper, as funds are very limited. Your honesty is relied upon in paying what you can so that we can help as many people as possible. Make all checks and money orders payable to Camp Dream Foundation, and mail to: 4355 Cobb Pkwy. Ste J117 Atlanta, GA 30339. 

Sponsor Information

If you have a Sponsor for your camper please provide the following information: (if other than parent or guardian) 
No Camper is ever discriminated against because of age, sex, color, national origin, religion, disability or ability to pay! 

Refund Policy

Does your child have access to funds for summer camping sessions through a program such as Acumen? If so; please provide details as to what is needed in order to apply for these funds. 
Refund Policy
Camp Dream’s refund policy is designed to be as liberal as possible. Many of the associated supplies, and services must be paid for in advance, therefore refunds shall be granted according to the following policy.

If your child is not selected as a camper for this year’s camping session, your money will be returned in full.

Full refund will be made at your (or sponsor) written request 30 days before the beginning of the camping session for which your camper is scheduled. Refund requests less than 30 days will receive a 50% refund until the first day of the camp. Once the camper has arrived on Camp premises, no refunds are possible. 
$500 is suggested but amount can be modified.