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

Camper's Name	Gender male female
School Grade	Age at time of retreat
Date of birth

Race/Ethnicity

African American
Caucasian
Latino/Hispanic
Multicultural
Other

Emergency contact Phone number
(This person should be someone who will not be attending the retreat/camp)

Physician's name Phone number

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

1. Limitations on Activities

2) Special Equipment Used:

3) Special Accommodations:

4) Disabilities (developmental, emotional, or physical):

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.

1) Are the applicant's immunization records up to date and complete? (please circle one) yes no

2) Date of last tetanus shot:

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.

3) Date of last TB Test:

Test results (please circle one) positive negative (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.

4) List any chronic health problems (e.g. asthma, seizures, cough) and treatments of which Red Ribbon Trails should be aware:

5) Camper's HIV Status: (please check one)
Asymptomatic HIV
Symptomatic HIV
AIDS
Negative

Allergies

1) Does the applicant have any known allergies? yes no

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? yes no

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? yes no

2) Has the applicant attended a Red Ribbon Trails retreat/camp before? yes no

3) Has the applicant ever been sent home early or denied admission to a retreat/camp? yes no
If yes, explain:

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

5) Has the applicant ever had swimming lessons? yes no

If yes, how many years?