STROKE RETREAT 2016 — CAMPER APPLICATION (Full Weekend)
Please complete all the requested information in each section. Return with your registration fee of
$75.00/person ($35.00 for children age 5-14, children under 5 are free), payable to Henry Ford Health
System (please put stroke retreat on the memo line) and mail to:
Stroke Retreat
Henry Ford Health System
Surgery Admin-CFP 126
Attention: 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 are independent and 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:
ZIP:
Sex:
Is this person?

Caregiver attending camp

Companion attending camp

Emergency Contact for
transportation
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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.
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
Details ___________________________
 Yes
 No
Assistance to stand
Details ___________________________
 Yes
 No
Assistance to transfer
Details ___________________________
 Yes
 No
Assistance with dressing
Details ___________________________
 Yes
 No
Assistance with toileting
Details ___________________________
 Yes
 No
Assistance with bathing
Details ___________________________
 Yes
 No
Assistance with eating
Details ___________________________
 Yes
 No
Special positioning in bed
Details ___________________________
 Yes
 No
Turning in bed at night
Details ___________________________
 Yes
 No
Urinal/bed pan at bed side
Details ___________________________
 Yes
 No
Other assistance requested: _____________________________________________________________
Please list medical equipment necessary for this camper. You should being needed equipment to camp. (A
limited number of 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:

Will you or your family require a special diet?
Yes

Please
describe
any
assistance
you may
require
during
camp:
No
If yes, please describe the special diet and include the names of all family members who require the diet:
Cabin Assignments
You will be placed into a cabin with compatible families or same sex groups. Cabins are rustic and have beds for 6-8
people, with one bathroom and one changing room. (You will need to bring your own bed linen and towels.) Please mark
cabin preference below. We will try to match cabin mates as appropriate and as space allows.


Female cabin

Male cabin

Couples cabin (adults only)

Family cabin (children)
No cabin reservation needed. Will stay off-site. (Campers staying at local hotels are responsible for payment and for making
their own hotel reservations. A list of hotels will be sent to you.)
Please list other individuals or family members you wish to room with:
(Please note: We will do our best to accommodate your wishes to keep larger groups together, but we must consider
safety and cannot over-crowd rooms with people and/or equipment. Room assignments are made at the discretion of the
Stroke Camp Director and Medical Director and are subject to change as needed.)
Do people in your party tend to go to sleep?
 Early—please list names: ____________________________________________________________
 Late—please list names: ____________________________________________________________
Do people in your party usually sleep?
 Lightly—please list names: ___________________________________________________________
Does anyone in your party snore loudly enough to be distracting to others?
If yes, please list names:
_______________________________________________________________
We are concerned about sleep this weekend:

Very*

Moderately*

Yes


Not Very
No
*We suggest bringing earplugs if you checked either of these!
Please list any other information you feel we should know about your family:
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