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Red Ribbon Trails

(A program of FCAN)

Camper Application Form

 

Check one:

Each camper in the family must complete an individual Camper Application.

male female
 

Race/Ethnicity







(This person should be someone who will not be attending the retreat/camp)


Camper Profile
This information will be used to determine whether the applicant's needs may be met adequately. Retreat/Camp personnel will also use this information in best meeting the applicant's needs while at the retreat/camp. Please be as open and complete as you can in answering questions. All information is confidential.

Physical Condition




Medical History
The following information is mandatory. Applicants without up to date immunizations will not be invited to participate at the retreat/camp. Please contact your case manager for assistance in gathering medical history information.



Red Ribbon Trails recommends that all attendees have had a tetanus shot within the last 10 years or receive a booster before attending a Red Ribbon Trails event.

(TB Tests are recommend but not required.)
Red Ribbon Trails recommends all attendees to have been tested for TB within the last year.  Those who have tested positive for TB in the past must provide a letter, (dated within the last year), from their physician advising of their TB status and their ability to attend and/or work at a retreat/camp with immune comprised attendees, including HIV+ persons, to attend Red Ribbon Trails events.





Allergies

1) Does the applicant have any known allergies?

If yes, please describe the allergies:


Medications

1) Please list any Prescribed Medications taken



2) Will the camper be bringing any medication that will require refrigeration?


Behavior

1) Please describe any behavioral or emotional problems that the camper is experiencing such as unusual aggression, anger, mood swings, depression, or social awkwardness:

2) How should any of these behavioral or emotional problems be addressed? What words are used?


Eating Habits

1) Please list any dietary restrictions, needs, or food allergies:

Past Camping Experience

1) Is the applicant prone to wandering or running away?

2) Has the applicant attended a Red Ribbon Trails retreat/camp before?

3) Has the applicant ever been sent home early or denied admission to a retreat/camp?
If yes, explain:

4) What is the applicant's level of swimming?

5) Has the applicant ever had swimming lessons?

If yes, how many years?

If the applicant named above is under the age of 18, all initials and legal signature must be signed by their Parent/Legal Guardian. Please download the form below, sign and return to:
Red Ribbon Trails
c/o Deborah Vazquez,
53 W. Jackson #304
Chicago, IL 60604

Fax 312/786-9203

Click here to download PDF form.

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