Family Support Network | 4225 TAMU | College Station, TX 77843-4225
phone: 979.862.2913 | fax: 979.862.1256 | fsn@tamu.edu
Camper Application
Instructions
1) Drop off: Friday at 7:00 p.m. | Pick-up: Sunday at 10:30 a.m.
2) Complete each page of your child’s application and submit along with appropriate payment for camp.
3) All applications must be received complete with payment. Campers are accepted on a first-come, first-served basis,
so send in your application as early as possible to reserve a spot! Send your completed application and check to:
Camp LIFE c/o Family Support Network
4225 TAMU
College Station, TX 77843-4225
4) After the Family Support Network receives your application, you will be sent a letter (two weeks prior to camp start
date) stating whether you have been accepted or have been placed on the waiting list. In your acceptance packet, you
will receive instructions for check-in and check-out.
5) Kids with disabilities aged 5–21 and their siblings without disabilities aged 5–12 are eligible for camp.
Camp LIFE Fees
Realizing that families have different abilities to pay, Camp LIFE has instituted a voluntary two-tier fee program. You may
choose the tier that is most suitable for your family.
Tier I is a partially subsidized fee for those who can pay a little but still cannot afford the entire cost of camp.
Tier II more closely accounts for the true costs of camp.
Camp LIFE strives to provide an inclusive environment and therefore campers with disabilities may be accompanied by
their non-disabled siblings. Each camper fee includes housing, food, t-shirt, counselor costs, on-site medical staff costs,
and all camp supplies for each camper. There is a limited amount of stipend support available. Please complete and
submit your application with a letter stating need and amount you are able to pay.
Name of parent/guardian: _______________________________________________________________________________________________________
Name(s) of campers(s): _________________________________________________________________________________________________________
 Tier I - $250 per camper
 Tier II - $350 per camper
Check #:_______________ Check Amount: $_______________ Includes additional campers?
 Yes
 No
Please include payment with your application. Your application will not be processed without payment! Checks will not be
deposited until the camper is accepted. One check may cover multiple campers. Camper fees are non-refundable after
three weeks prior to camp. Make checks payable to “Family Support Network.” Campers who are financially assisted by
agencies/organizations are asked to pay full fee (Tier II).
General Camper Information
Name ________________________________________________ DOB ___________ Age ______ Male Female
Home address __________________________________________________________________________________________________________
City ________________________________________________________________________ State _________________ Zip_________________
Email address __________________________________________________________________________________________________________
In case of an emergency, we will use the following information to contact you.
Main phone (_______) _______________________________ Alt. phone (_______) _______________________________________
Mother’s name ____________________________________________ Father’s name______________________________________
Emergency contact’s name (non-parent) __________________________________________________________________________
Emergency contact’s phone (_______) ______________________________ Relationship _______________________________
T-shirt size (circle one): Youth M Youth L Youth XL Adult S Adult M Adult L Adult XL
Has your child ever spent a weekend away from his parent(s) before?  Yes  No
Comments: _________________________________________________________________________________________
 No
Has your child ever attended… Camp LIFE?  Yes
Another camp?  Yes  No
Comments: _____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Describe any parent/guardian child custody issues staff should know. ____________________________________________________
________________________________________________________________________________________________________________________
Camper Overview (this section will be provided to your child’s counselor)
Name ___________________________________________Chronological Age _____________________  Male  Female
My child’s behavior is similar to a _________ year old.
Approx. height __________________ Weight _________________
Languages Used  English
 Spanish
 ASL
 Other: ___________________________________________
Chief Diagnoses (list all: e.g., seizures, asthma, MR, CP, AU, ADHD) Seizures  None Yes  One or two as small child
1)_____________________________________________
2) _________________________________________________________
3) _________________________________________________________
4) _________________________________________________________
5) _________________________________________________________
Allergies
 Yes (list below)
 No
Type _____________________________________________________
Last one__________________________________________________
Frequency ________________________________________________
Usual frequency __________________________________________
Usual duration ____________________________________________
Pre-seizure activity _______________________________________
Triggered by ______________________________________________
Foods ___________________________________________________
Medications______________________________________________ Ambulation  Walks assisted Walks unassisted
Other ___________________________________________________  Walks using ( Walker  Crutches  Wheelchair)
 Wheelchair ( Manual  Electric)
 Transfers ( Alone  Needs assistance)
Behavior
Additional Equipment
 No problems
 None
 Nebulizer Tracheostomy tube
 Problems triggered by ________________________ ____
 Monitors  Oxygen
 Ventilator
 Positive reinforcers ______________________________
 Other: _________________________________________________
 Discipline:
Communication
 Withhold privileges: _______________________
 No problems
 Non-verbal
 Sign Language
 Time out ( ________ min)
 Limited abilities, but can communicate daily needs
 Other: ________________________________________
 Communication device: _______________________________
Vision
Eating/Diet
 Normal  Limited  Blind  Glasses
Self-Care
 Does all alone  Needs help in all areas.
 Needs some help in: _______________________
_________________________________________
Toileting
 Regular diet  No help needed  Total assistance
 Needs help only with:
Food must be:  Cut  Chopped  Mashed  Pureed
 Special diet:__________________________________________
 Favorite foods:________________________________________
Activities
Does child have PE tubes in ears?  Yes  No
Heat tolerance:  Good
 Fair
 Poor
Does your child wander?
 Yes
 No
Restrictions:___________________________________________
 Toilet trained  Training pants  Diapers
 Take to bathroom every __________ hours.
 Needs help with _______________________________________
Additional Instructions (e.g., My child is afraid of the dark.)
 Caths every ______ hours. Self-cath?  Yes  No
_____________________________________________________
_____________________________________________________
Sleep
_____________________________________________________
(Usually sleeps from ______ pm – _______ am)
 Regular bed
 Wakes at times during night
 Toddler bed
 Walks in sleep
 Needs bed rails
 Wets bed
 Needs floor trundle  No sleep problems
Medical Information
Major Surgery (past 3 years)
1) Type:_____________________________________________________________________________ Date:______________
2) Type:_____________________________________________________________________________ Date:______________
3) Type:_____________________________________________________________________________ Date:______________
Hospitalizations (past 3 years)  No  Yes (please explain): ___________________________________________________
________________________________________________________________________________________________________
Immunizations Date of last tetanus shot:________ Other immunizations up to date?  Yes  No
Emergency Information
Child’s Regular Hospital:_____________________________________________________________________________________
City: _____________________________________________________________________________________________________
Child’s Regular Physician:____________________________________________________________________________________
Office Phone:_____________________________________ Cell Phone:_______________________________________________
Medications
Please provide all information about each medication your child takes. Follow the sample provided. If you need more room,
please attach an additional sheet. All medications must be brought to camp in their original bottle OR individually
sealed by the pharmacy. If medications change prior to camp, please tell Medical Staff at check-in.
Prescription Medications (mg)
Amount Given
Times Given
Special Instructions
Ex: Phenobarbital (32 mg)
Phenobarb Liquid (20 mg/5cc)
1 tablet
1 teaspoon
8am, 8pm
9am, 4pm
Drinks only with milk
Give via G-tube with water
Please include any additional medical information on a separate, attached page.
You will also be able to speak directly with the Camp Director and/or medical staff at check-in.
Permissions (please INITIAL yes or no––do not check!)
Yes
No
______
______
______
______
______
______
______
______
______
______
______
______
1) I give my child permission to attend the Family Support Network’s Camp LIFE. He/she may
participate in all activities except those noted on “Activity Restrictions” (page 3).
2) The medical staff at Camp LIFE may administer my child’s routine medications and over-the-counter
medications, monitor health status and provide first aid and routine care.
3) If emergency treatment is necessary, I give permission for my child to be brought to the nearest
emergency room by ambulance or helicopter for treatment. I authorize staff to release all records
necessary for insurance purposes so that my insurance company can be billed for the visit, lab tests,
and/or x-rays, if necessary. If time and circumstances permit, I would prefer my child be taken to his/her
regular hospital listed under “Medical Information” (page 4).
4) For non-emergency purposes, my child may ride in a privately owned vehicle with medical staff to the
hospital for lab tests, x-rays or treatment.
5) I will provide all necessary medications and supplies needed by my child for the camping session.
However, if my child requires any additional prescription medications, I give the medical staff
permission to obtain these and bill upon my notification.
6) I give Camp LIFE permission to use my child’s name, photograph or video image for publicity purposes.
Camper name _________________________________ Parent/legal guardian printed name ________________________
Parent/legal guardian signature _________________________________________________ Date ___________________
Mail completed application(s) with appropriate attachments and payment to:
Camp LIFE c/o Family Support Network
4225 TAMU
College Station, TX 77843-4225
Questions? Contact Aimee Day at 979.862.2913 or fsn@tamu.edu