Camper Application for Girls Weekend Getaway

Welcome to the Camp Daniel Online Application! You have the option to Save & Resume by clicking the checkbox and following the prompts. At the end, you will click "Proceed to Review", and you will be able to review, print, and submit your application. You will also receive a PDF copy of your submitted application via email after the final submission.

If the Applicant attended Summer Camp this year, then you will not need to submit another Physician Form. Only one Physician form for all programs in the 2024/2025 Camp Season!

If you have any questions regarding Registration, contact registrar@campdaniel.org.
If you have any technical support questions regarding completing this application, you may email support@campdaniel.org or call (715) 891-0528 between 9am-9pm.

Let's Get Started!

Who is filling out this Application?

Your Name

The person filling out the application

Relation to Applicant

What is your relation to the Applicant?

Your Email

The person filling out the application.

Applicant

First Name

M.I.

Last Name

Preferred Name

Date of Birth

Sex

Street Address Line 1

Street Address Line 2

City

State

Zip Code

County

Phone Number

Has the Applicant attended Camp Daniel in the Past?

No, First TimeYes, Returning"Attended" refers to having previously completed an application to attend summer camp or weekend getaway.

ERROR: Girls Weekend Getaway is for Females ONLY.

First Time Applicant Portrait

All First-Time Applicants must provide a photo.

Note: Applications will not be processed until a photo is received.

File name

Want to send it a different way?

Yes, by mailYes, by email

If you wish, you may mail in the photo to: Camp Daniel W10541 Army Lane, Athelstane, WI 54104. Be sure to include the Applicant's full name with the photo.

If you wish, you may email in the photo to: forms@campdaniel.org. Be sure to include the Applicant's full name with the photo.

Contact Person

The Contact Person will be the main point of contact regarding the status of this Application.

First Name

Last Name

Contact Person's Relationship to Applicant

Phone Number

This email will receive ALL communications for this Applicant.

How did you hear about Camp Daniel?

Is Applicant their own guardian?

Yes, Applicant is their own guardianNo, Applicant has a guardian

Guardian

First Name

Last Name

Guardian's Relationship to Applicant

Guardian's Email

Primary Phone Number

Secondary Phone Number

Street Address Line 1

Street Address Line 2

City

State

Zip Code

Emergency Contact

First Name

Last Name

Emergency Contact's Relationship to Applicant

GuardianParentSiblingGrandparentAunt/UncleStaffOther

Primary Phone Number

Secondary Phone Number

Additional information regarding emergency contact during camp:

Will the Emergency Contact be available during the duration of the program to pick up applicant if he/she is sent home for medical or disciplinary reason?

YesNo

Want to add a 2nd Emergency Contact?

YesNo

2nd Emergancy Contact

First Name

Last Name

Emergancy Contact's Relationship to Applicant

GuardianParentSiblingGrandparentAunt/UncleStaffOther

Primary Phone Number

Secondary Phone Number

Additional information regarding emergency contact during camp:

Will the 2nd Emergancy Contact be available during the duration of the program to pick up applicant if he/she is sent home for medical or disciplinary reason?

YesNo

REQUIRED

There has to be at least one emergency contact who is available during the duration of the program to pick up applicant if he/she is sent home for medical or disciplinary reason.

Does Applicant have a Social Worker or Case Worker, or an IRIS Consultant?

Yes, Social WorkerYes, Case WorkerYes, IRIS ConsultantNo

Social/Case Worker/IRIS Consultant

Social/Case Worker or Consultant Name

Agency Name

Agency Phone Number

Applicant resides at:

Family's HomeFoster HomeGroup or Adult Family HomeSupported Living/Sheltered ApartmentIndependent Apartment/HomeNursing HomeOther

Explain Other residence type:

Residence Contact Info

Home Name

Home Manager Name

Administrator's Name

Administrator's Phone Number

Staff Member Name

Staff Phone Number

Experience Away from Home

Has Applicant had prior experience away from home?

YesNo

Please describe prior experience away from home:

Religious Services

Does Applicant attend Religious Services?

YesNo

Which most accurately describes how often applicant attends religious services?

WeeklyMonthlyYearly

Church Denomination

Describe other denomination:

Church Name

Church City

Employment

Is Applicant employed?

YesNo

Applicant's Employer

Job Description

Extracurricular Activities

Does Applicant participate in Special Olympics?

YesNo

Which Special Olympics events?

Alpine SkiingAquaticsBasketballBocceBowlingCross Country SkiingFlag FootballGolfGymnasticsPowerliftingSailingSnowboardingSnowshoeingSoccerSoftball/Tee BallTennisTrack and FieldVolleyball

List other Activities/Groups that Applicant is involved in:

Camp Activities

Camp activities:

Applicant may participate in ALL activities.There is activity/activities the Applicant may NOT participate in.

List and Explain activity/activities the Applicant should not participate in:

Animals (rabbits, dogs, horses, etc):

Applicant is comfortable around animals.There are some animals the Applicant may NOT be comfortable around.

Please explain:

Water Activities: Check All that apply

Fears WaterDoes not like to swim or is not able to go in the water at all.Wades or swims in Shallow WaterSwims in Deep Water

Does Applicant wear Ear Plugs?

Uses ear plugs for Some Water Activities (submersion only)Uses ear plugs for ALL Water Activities (submersion & splashing)No

Physical Disability/Limitations

Check All that Apply:

Visually Impaired (any kind)Hearing ImpairedAsthmaHeadachesDiabetesSeizures (past and present)Heart Condition (including hypertension)Brain TraumaCerebral PalsySpina BifidaSpinal Cord InjuryMuscular DystrophyMultiple SclerosisStrokeOtherNone of the Above

Please describe "Other" physical disability/limitation

Physical Limitations: Please give additional information regarding any above checked items:

Visually Impaired

Wears Glasses/Contacts

YesNo

Is Applicant Legally Blind?

YesNo

Explain visual impairment and tools/techniques used:

Hearing Impaired

Wears Hearing Aid(s)?

YesNo

Uses Sign Language?

YesNo

Please describe sign language usage:

Describe frequency, treatment, history and severity of Headaches

Diabetes

Type of Diabetes

Type 1Type 2

Does Applicant Require a Special Diet for Diabetes?

Yes (continue in "Eating")No

Which option most closely describes the required diabetes management?

Pre-diabetes only- NO medication or insulinControlled diabetes - takes medication, but NO insulinDiabetes that requires medication AND insulin

Additional information regarding Diabetes:

Seizures

Applicant's most recent seizure was:

in the past month.between 1-6 months agobetween 6-12 months agobetween 1-5 years agomore than 5 years ago

Type of Seizures

Frequency of Seizures

Length of seizure and recovery time

Date of last Seizure and Treatment

Behavior/Aura Prior to Seizure

Describe cause of Spinal Cord Injury

Describe cause of Brain Trauma

Intellectual/Developmental Disability

Yes, Applicant DOES have an Intellectual/Developmental DisabilityNo, Applicant does NOT have ANY Intellectual/Developmental Disability

Level of Mental Function:

Mild disability -Ex: IQ 50-70 , reading 3-6 grade, can learn life skillsModerate disability -Ex: IQ 35-49, simple communication skills, performs self-caresSevere disability -Ex: IQ 20-34, poor communication skills, simple self-cares, needs supervision in social situationsProfound disability -Ex: IQ Less Than 20, help with all self-cares, very limited communication

Check All that apply: Cognitive/Developmental DelayDown SyndromeADD - Attention Deficit DisorderADHD - Attention Deficit with Hyperactivity DisorderASD - Autism Spectrum DisorderFetal Alcohol SyndromeFragile X SyndromeWilliams SyndromeOther intellectual/developmental diagnosis not listed above	Describe Intellectual/Developmental Disability, history and help needed:
Please describe "Other" Intellectual/Developmental Disability:

Mental Health

Does Applicant have any of the following?:

DepressionAnxietyPanic AttacksDementiaOCD - Obsessive Compulsive DisorderODD - Oppositional Defiance DisorderBipolar DisorderSchizophreniaOther Mental Health issues

Describe all checked Mental Health conditions.

Include frequency, severity, techniques used by caregivers, etc.

Dementia: Describe level of deterioration in the last 12 months.

Has Applicant had Inpatient Hospitalization for Mental Illness?

YesNo

Date & Describe Hospitalization:

Mobility & Special Equipment

Does Applicant have ANY Mobility Limitations?

YesNo

Applicant Walks:

alonewith minimal assistancewith support from another personnon-ambulatory

Reason for non-ambulatory:

Has ParaplegiaHas QuadriplegiaNeither

When walking, Applicant is generally:

StableUnsteadyFalls Easily

Applicant generally walks:

SlowMediumFast

Check All that apply:

Uses WheelchairUses WalkerUses Gait BeltUses SplintsUses CrutchesUses Brace(s)Uses CaneUses HelmetHas ProthesisOther Equipment not listed

Wheelchair is:

ManualElectric

What % of waking time is spent in wheelchair?

0%-33%34%-66%67%-99%100%

Applicant transfers:

AloneMinimal assistanceSupport from another personNon-weight bearing

Applicant manipulates wheelchair Independently:

YesNoPartially

Explain "partial" wheelchair manipulation:

Explain uses of Equipment and all Mobility Constraints and what is needed for Mobility Assistance.

I understand that ALL Mobility & Special Equipment must be sent to Camp.

Yes, I understand

Reading/Writing Skills

Is Applicant able to Write?

YesNo

Is Applicant able to Read?

YesNo

What is Applicant's reading level?

Communication

Communication Skills:

Applicant has NO problems CommunicatingApplicant has problems Communicating

Verbal Ability

Limited verbal abilityNon-verbal

Check All that apply:

Able to Communicate Wants/NeedsResponds to QuestionsUnderstands Simple DirectionsReads LipsUses GesturesUses Sign LanguageUses Language BoardUses Pictures or Word CardsUses Computer/TabletNote: Bring all communication devices to camp.

Describe Applicant's Communication Skills and Needs

Personality/Behavior

Is Applicant's Behavior Appropriate in a Group Setting?

YesNo

Explain Behavior in Group Setting:

Applicant's predisposition:

Always CompliantCan be Non-Compliant

Check All that apply:

SocialHelpful to othersShy or WithdrawnStubbornProne to LyingSensitive to loud soundsTemper TantrumsSelf-Stimulates (ex: rocking, clicking, grinding teeth)WandersRuns away (from people or places)Prone to DepressionPhysically AggressiveVerbally AggressiveDoesn't like to be TouchedSelf AbusiveOverly AffectionateAttaches to People of the Opposite SexSexually ActiveAny History of being Physically AbusedAny History of being Sexually AbusedCurrently Smokes/Vapes

Explain Self-Stimulation, including triggers and distraction techniques.

Describe all checked Personality & Behavior Items

Personal Care/Hygiene

Washing Hands/Face

IndependentNeeds ReminderNeeds Help

Brushing Teeth

IndependentNeeds ReminderNeeds Help

Showering

IndependentNeeds ReminderNeeds Help

Shaving

IndependentNeeds ReminderNeeds HelpN/A

Washing Hair

IndependentNeeds ReminderNeeds HelpN/A

Dressing

IndependentNeeds ReminderNeeds Help

Menstruation

IndependentNeeds ReminderNeeds HelpN/A

Additional Hygiene Notes:

Toileting Care

Toileting Care:

Needs NO AssistanceNeeds Assistance

Needs Toileting Reminder:

YesNo

How often?

Applicant can sometimes be incontinent:

During the DayDuring the NightExtra Bedding & Clothing MUST be sent with Applicant to camp.

For toileting, Applicant uses:

Disposable undergarments during the DayDisposable undergarments during the NightPortable Urinal/Commode during the DayPortable Urinal/Commode during the NightCatheterCheck All that apply

On Average, how many undergarments used per 24Hr period?

Please pack that many for each day and also add an extra 7, as most campers use more than normal during camp.

Describe Toileting Schedule & Bathroom Habits:

Eating/Diet

Applicant's Appetite is:

PoorGoodExcessive

Explain Excessive Eating:

Rate Applicant Eats is:

Normal RateVery FastVery Slow

Does Applicant need help during meals?

YesNo(including portion control)

Needs assistance with:

Cutting foodPortion controlMaking good food choicesFeeding tubeOtherCheck All that apply

Applicant has Difficulty:

ChewingSwallowing solidsSwallowing liquidsCheck All that apply

Applicant requires:

Pureed FoodsChopped FoodsStrawsSpecial utensilCheck All that apply

Explain "other help with food"

Is Applicant allowed second servings?

YesNo

Check ALL that apply:

Food allergyFood intoleranceSpecial diet (including, but

not limited to Diabetic)

Dietary Supplement

Regarding Soda:

Quantity needs to be limitedDiet onlyCaffeine-free onlyCheck All that apply

Explain quantity limits for Soda

Please explain all Checked Items regarding Food and Eating.

Dietary needs Contact Person

Dietary needs Contact Phone Number

Sleeping

Bunk

Applicant Can Sleep on Upper BunkApplicant Must Sleep on Bottom BunkLimited number of bottom bunks available. Only select Bottom Bunk if the Applicant MUST sleep on bottom.

Applicant's Typical Wake Up Time:

Applicant's Typical Bedtime:

Sleeping: Check All that Apply

Sleeps soundlyRestless sleeperTalks in sleepUses special equipment - Including C-papUses bathroom at nightWanders at nightSnoresRequires bedrail

Describe How Loud snoring typically is:

Describe Special Equipment used for sleeping:

Note: C-pap user must bring distilled water.

How often does Applicant use Bathroom during Night?

Explain Night Wandering:

Addition information regarding sleeping routine:

Health Insurance

It is our policy to have this information on file in case of an emergency.

Insurance Company

Insurance Policy Holder's Name

Applicant's Name unless under parent or guardian's policy

Insurance Policy Number

Medicare calls it "Claim number", Badgercare uses "ID Number", Obamacare uses "Member Number"

Insurance Group Number

Usually for Private or Employer insurance plans only

Does Applicant take any medications, vitamins, or supplements?

YesNo

Required: YOU MAY NOT SEND IN THIS INFORMATION ANY OTHER WAY.

Applicant will Not be accepted, if these fields are not accurately filled in.

Pharmacy Information

Pharmacy Name

Pharmacist's Name

Pharmacy Phone Number

Medication/Supplement

Name of Medication

Generic or Name-brand may be used. Do not add any additional information.

Dosage

Must include a number and unit of measure (mg, iu, or ml). This does not refer to how often med is taken.

General reason for this Medication

Fill in the number of pills/capsules taken at each of the following times.

8 am

12 pm

5 pm

8 pm

During camp, medications are administered at the times listed below.

Additional Information

Add any additional information needed for proper administration of this medication.

Caregiving Notes

Last Chance! Please note anything that would be helpful to caregiving for this applicant that has not yet been noted in the application.

Program Registration

Event Date: February 28 - March 2, 2025

Year

An email confirming acceptance will be sent 30 days prior to the program(s) which applicant is accepted. If you have not received an acceptance or denial email 30 days prior to the first program, then the applicant is automatically put on a waiting list. If the applicant cannot be accommodated into a camp this season, a full refund will be issued.

Group Info

Please try to accept applicant with a group:

YesNo

Name of Group

Note: All members of group should use the same Group name with the same spelling.

Names of All Applicants in Group

List any person that Applicant should NOT be at camp with and a brief explanation why:

If none, then leave blank.

Shirt Size

A Camp Theme T-shirt is only included with Summer Camp Program Fee.

T-Shirt Size

Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Adult SmallMediumLargeX-LargeXX-LargeXXX-Large

T-Shirt Cut

UnisexLadies Cut

Applications submitted after application deadline - We cannot guarantee your preferred shirt size, because of our ordering deadline.

Program Cost: $210

Cost after "Pay When You Apply" Discount: $165

“Pay When You Apply” Discount Terms

• Payment must be made online at the time of completing registration OR a check must be postmarked within 7 days of completing the online application to qualify for this discount.

• Payments made by Agency/County do not qualify for this discount.

Important:

Before selecting “Agency/County” as your payment option, please confirm with your agency/county that they will cover the program fees. If payment is not received within the 7-day period (via personal payment), you will not qualify for the “Pay When You Apply” discount.

Who will be paying the Program Fee?

ApplicantPayeeGuardian or ParentAgency or CountyOther

How would you like to pay the Program Fee?

Pay now with Credit/Debt CardMail in a check

How would you like to pay Snack & Gift Shop?

Pay now with Credit/Debt CardMail in a check

Briefly describe "other" Person paying

Other Person Paying: Relation to Applicant

Mail in Check

If you wish, you may mail in the check to: Camp Daniel W10541 Army Lane, Athelstane, WI 54104. Be sure to include a copy of the Fee Schedule with the Applicant's Full Name.

Agency/County Payments

It is your responsibility to acquire and submit an Authorization from the paying Agency/County. Check with your Agency/County before choosing this payment option so that we may qualify for the "Pay When You Apply" discount.

The Application will NOT be processed until an Agency/County Pre-Authorization is received.

Name of Agency/County that will be Paying

If IRIS, put the name of your Fiscal Employer Agent (FEA).

Agency/County Contact Name

Social worker, case worker, or IRIS consultant

Agency City

Agency/County Contact Email

Social worker, case worker, or IRIS consultant

Would you like us to send a Courtesy Notification to the paying Agency/County?

NoYesThis notification will be in the form of an email and will include all the relevant information needed for the Agency/County to provide a Pre-Authorization. Note: It is still your responsibility to acquire and submit the Pre-Authorization.

Fee Schedule

Girls Weekend Getaway

Program Fee

How much Money for Gift Shop?

$30-75 recommended

How much Money for Snacks?

$20-30 recommended

Total

Snack & Gift Total

Enter Payment Information

Name on Card

Billing Email

Card Number

CVV

Enter Billing Address

First Name

Last Name

Address Line 1

Address Line 2

City

State

Postal Code

Policies Applicable to Campers

Applications: Camper applications are available to individuals 8-80+ years old who have a physical and/or intellectual or developmental disability. Each applicant is accepted on an individual basis (see Acceptance). Camp Daniel does not discriminate on the basis of race, religion, creed, or national origin. A completed application includes: Physician Form, First Time Camper Portrait, and Fee Schedule Paid-in-Full. Agency Pre-Authorization without payment satisfies payment requirements to begin processing completed application, but does NOT qualify for discount.
Medications: If there are 3 or more medications/vitamins administered per day, then they must ALL be bubble packed by pharmacy. If there are 2 or less medications/vitamins administered per day, they may be either: sent in the original container with accurate, unaltered pharmacy label, or bubble packed by pharmacy. Camp nurse will administer all medications and vitamins as directed by a physician on original pharmacy label. Send only enough meds of the duration of camp. (see Medication Policy for complete details)
Acceptance: The Acceptance Process begins with a completed application (see Applications). Acceptance is firstly based upon our ability to find a suitable counselor for applicant, and secondly, on the timeliness and thoroughness of the application. An email confirming acceptance will be sent 30 days prior to the program(s) which applicant is accepted. If you have not received an acceptance or denial email 30 days prior to the first program, then the applicant is automatically put on a waiting list. If the applicant cannot be accommodated into a program this season, a full refund will be issued (see Refunds).
Behavior: For the safety of everyone at the camp, we do not accept applicants with extreme behavior problems. This includes applicants that are physically, verbally or sexually aggressive. If an applicant does not follow rules or take direction from staff, or any behaviors, which endanger others or are disruptive to the camp, are grounds for non-acceptance to camp or immediate dismissal from camp. Applicants must be able to sleep in a cabin setting, not wander in the night, or disturb others through their behavior. All applicants must be able to function in a group setting.
Dismissal: If the applicant is sent home for medical or disciplinary reason, an emergency contact must be available during the week and is responsible for transportation home within 12 hours of notification (see Refunds). Any behaviors, which endanger others or are disruptive to the camp, are grounds for non-acceptance to camp or immediate dismissal from camp.
Payment: The cost of camp sessions is listed on the current year’s Fee Schedule. Payment maybe paid online with a credit/debit card while filling out the application or by sending a check. It is the responsibility of the applicant to notify payee Agency to acquire and submit Letter of Authorization from Agency to provide services.
Snack & Gift Shops: Tickets (for the amounts designated in the Fee Schedule) will be issued for use as payment at the snack shop and gift shop.
Cancelations: A $25 processing fee will be retained and the balance of the paid camp fee will be returned.
Refunds: All discount and dismissal refunds will be issued after the completion of the camp season. No refunds will be issued if sent home for disciplinary reasons. Partial refunds will be issued for medical reasons. Full refunds will be issued to unaccommodated or denied applicants, minus any credit card processing fees.
Lost Items: Camp Daniel is not responsible for lost or stolen articles that have not been properly marked with applicant's name. Any unmarked item brought by applicant may be labeled with camper name by Camp Daniel Staff.
Prohibited Items: No vape, CBD, tobacco, alcohol, drugs, firearms, or knives allowed on the grounds. Food and drink items are not allowed in the cabins.
Dress Code: No crop tops, spaghetti straps, or short shorts. Any leggings must be worn with a shirt that covers butt. Any two-piece swimsuit must cover stomach, or be worn with a dark shirt. No speedos allowed.

Terms and Conditions

All the information provided on this application is accurate and true and I agree to all the conditions contained in this application.

I agree to the above mentioned camp policies and acceptance policies.
I understand precaution is taken to safeguard the health and safety of the applicant under Camp Daniel's supervision. I waive, release and discharge any and all claims for damages of death, personal injury or property loss which I, or the applicant named on this form, may have as a result of participation in Camp Daniel activities.
I hereby give permission to the medical personnel selected by the camp director to administer first aid, and to order routine tests and treatments. In case of medical emergency, I understand that every effort will be made to contact the applicant’s emergency contact(s). In the event that anyone cannot be reached, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the applicant named on this form. I understand that I am responsible for all medical related expenses, including those for prescription drugs and over the counter medications.
I hereby grant Camp Daniel authorization to use applicant's name, image and likeness, and sound and video recordings for promotional purposes and in social media.
I, the undersigned, hereby acknowledge that I have read the foregoing, understand its content, give permission of the applicant to attend summer camp at Camp Daniel and have signed the same as my own free act and deed.

I have read and accept the Camp Policies and Terms & Conditions

Yes, I accept

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When you click Submit, you will be able to review and print your application. After your final submission, you will be redirected to a webpage where you will be able to download/print the Physician Form, Fee Schedule, and Medication Policy Info Sheet. You will also receive a PDF copy of your submitted application via email.