STROKE RETREAT 2016
CAMPER APPLICATION (Day Camp)
Please complete all the requested information in each section. Return with your registration
fee of $40.00/person ($25.00 for children age 5-14, children under 5 are free), payable to:
Stroke Retreat
Henry Ford Health System
Surgery Admin-CFP-126
Attn: Kissie Harris
2799 W. Grand Blvd
Detroit, MI 48202
Stroke Survivor
Name:
Address:
City:
State:
Phone:
E-mail:
Birth Date:
Age:
ZIP:
Sex:
Caregiver/Companion/Emergency Contact Please note that we encourage all stroke
survivors to bring a caregiver or companion with them. Please list them below. If you do not
have a caregiver or companion who is able to attend with you, please identify the name,
address and telephone number of an emergency contact who, in the case of an emergency,
is able to pick you up from camp or the hospital, night or day. (Camp volunteers are not
allowed to transport campers for liability reasons.)
Caregiver/Companion/Emergency Contact
Name:
Address:
City:
State:
Phone:
E-mail:
Birth Date:
Age:
Is this person?
 Caregiver attending camp

Companion attending camp
ZIP:
Sex:

Emergency Contact for transportation
All health-related or personal information being collected for the Stroke Retreat is
solely to be used in preparation for the event or in case of a medical emergency. All
information will be kept secured prior to, during the event, and after the event. All
forms will be destroyed or returned at your request.
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Information about Stroke Survivor
Date of Stroke: ____________________________ Type of Stroke (if known): _____________________
Physical Limitations
Weakness or Paralysis of:
 Arm
 Leg
 Face




Uses wheelchair
Uses walker
Uses cane
Visual difficulties
Communicative Status (Check all that apply)





Normal communication
 Talks in words only
Aphasia
 Talks in sentences
Dysarthria (slurred speech)
 Difficulty understanding what is said
Difficulty reading
 Difficulty writing
Nonverbal communicator
List devices used to communicate: _________________________________________________
Does stroke survivor require:
Assistance with stairs
Assistance to stand
Assistance to transfer
Assistance with dressing
Assistance with toileting
Assistance with bathing
Assistance with eating
Special positioning in bed
Turning in bed at night
Urinal/bed pan at bed side










Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes










No
No
No
No
No
No
No
No
No
No
Details ___________________________
Details ___________________________
Details ___________________________
Details ___________________________
Details ___________________________
Details ___________________________
Details ___________________________
Details ___________________________
Details ___________________________
Details ___________________________
Other assistance requested: _____________________________________________________________
Please list medical equipment necessary for this camper. You should being needed equipment to camp.
(Shower chairs are provided.)
Wheelchair powered  manual _________________________________________________________
Walker ______________________________________________________________________________
Braces, slings, etc. ____________________________________________________________________
Cane _______________________________________________________________________________
Other _______________________________________________________________________________
Is there any further information that may be helpful in better understanding the stroke survivor and his/her needs
at camp?
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Information about Caregiver, Companion and/or Family Members
Additional Family Members Attending Camp:
Name:
Age:
Sex:
Name:
Age:
Sex:
Name:
Age:
Sex:
Name:
Age:
Sex:
Please describe any assistance you may require during camp:
Will you or your family require a special diet?

Yes

No
If yes, please describe the special diet and include the names of all family members who require the diet:
Please list any other information you feel we should know about your family:
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