Arizona Children's Burn Camp - CAMP COURAGE
Pine Summit - Prescott, Arizona


Campers must be between the ages of 6-15 years old by June.


Basic Info
* First Name
* Last Name
Date of Birth
Gender
Address 1
Address 2
City
State
Zip Code
School Name
Grade next fall
Special Ed
YesNo
If yes please explain
Does camper speak fluent English?
YesNo
Is camper bilingual (English/Spanish)?
YesNo
T-Shirt Size
Camper Resides with
Other Residence
Who has legal custody:
Other Legal Custody
Number of Siblings
Name(s) of Sibling(s)
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian First Name
Parent/Guardian Last Name
Home Phone
Cell Phone
* Email
Background Screening
Has this child ever been convicted of a misdemeanor?
YesNo
Has this child ever been convicted of a felony
YesNo
Has this child ever spend time in prison/correctional institution?
YesNo
If you answered yes to any of the questions, please explain
Does this child have a court caseworker/probation officer?
YesNo
Caseworker/Probation Officer Name
Burn History / Therapy
Place of hospitalization
Length of stay
Date of burn
Percentage of body burned
Parts of body burned/affected by treatment(s)
Is child currently receiving burn therapy?
YesNo
Status of burn therapy
If yes, where?
Has the child been in for surgery in the past 6 months?
Does the child require special medical needs due to recent surgery?
YesNo
If yes, list special needs
Is the child scheduled for more surgery?
YesNo
If yes, where and when:
Has the child ever consulted a physician, social worker, or therapist concerning an emotional problem?
YesNo
If yes, list name(s) and number(s)
Are there any physical/emotional traits the camp medical personnel should be aware of?
YesNo
If yes, please describe
Please Note: If this child is currently or has previously received counseling or therapy, a brief summary from the professional noting treatment as well as issues relevant to camp is required as part of the application process.
Medical History
Does the camper have any special medical needs?
YesNo
If yes, please describe:
Splint(s)
YesNo
Splint(s): Wearing Schedule
Splint(s): Description
Garment(s)
YesNo
Garment(s): Description
Garment(s): Wearing Schedule
Physical Therapy
YesNo
Physical Therapy: Description
Please upload detailed instructions from your Physical Therapist.
No file is currently uploaded.
Upload File
Dressings
YesNo
Dressing(s): Description
Dressing(s): Changing Schedule
Dental Appliances
YesNo
Dental Appliances: Wearing Schedule
Is the applicant currently taking any medication?
YesNo
Medication #1 Name
Medication #1 Frequency
Medication #1 Dosage
Medication #2 Name
Medication #2 Frequency
Medication #2 Dosage
Medication #3 Name
Medication #3 Frequency
Medication #3 Dosage
Medical Continued
Medical Conditions
Yes No
* Athletes Foot
* Diabetes
* Diarrhea/Constipation
* Difficulty Hearing
* Difficulty Seeing (blinks, squints, rubs eyes)
* Ear Infections
* Frequent Sore Throat
* Headaches
* Heart Trouble
* Indegestion/Vomiting
* Eczema
* Nose Bleeding
* Seizures/Fainting Spells
* Sinus Trouble
* Other Medical Issues
Please list other
Over-the-counter Medications
Yes No
* Bacitracin
* Benadryl
* Betadine
* Ibuprofen
* Maalox
* Sudafed
* Tums
* Tylenol
* Other Restrictions?
If yes, please list restrictions
Behaviors
Yes No
* Alcohol Abuse
* Bed Wetting
* Drug Abuse
* Sleep Walking
* Fears/Phobias
* Impulse Control
* Nail Biting
* Nightmares
* Thumb Sucking
* Other Behaviors?
If yes, please list other:
Allergies
Yes No
* Asthma
* Foods
* Hay Fever
* Insect Stings (bees, etc.)
* Penicillin
* Poison Ivy, etc.
* Other Allergies
Please list other allergies
Diseases
Yes No
* Chicken Pox
* German Measels
* Measels
* Mumps
* Rheumatic Fever
* Other Diseases
Please list other diseases
* Other operations or serious injuries?
YesNo
If yes, please list
* Chronic/Recurring Illness or Other Diseases
YesNo
If yes, please list
Transportation
Transportation to Camp
Phoenix Bus (for parents in the southern portion of the state who choose not to use Angel Flight as transportation, you can drive your campers to Phoenix to catch the bus- bus leaves promptly by 9:30am)
Tucson- Angel Flight
Yuma- Angel Flight
Parent will drive camper to camp (camper should be checked in at camp by 11am on Sunday)
Transportation home from camp
Phoenix Bus (for parents in the southern portion of the state who choose not to use Angel Flight as transportation, you can drive to Phoenix to pick up your camper(s) - bus arrives by 1pm from camp)
Tucson- Angel Flight
Yuma - Angel Flight
Parent will pick up camper and drive home from camp
* Name of Parent or Guardian
* Signature of Parent or GuardianUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
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Permission Slip for Activities
Activities - please select which activities you DO NOT want your child to participate in.
Hairstylists will be donating their time and talents to give Campers an opportunity to receive a haircut, hairstyle and/or manicure. Please check Yes for each activity your child may participate in.
Yes No
My child may receive a haircut and style
My child may receive a style only (light trimming is ok)
My child may have nails polished
Code of Conduct


Click here to read Camper Code of Conduct Full Text.
* Signature of parent or legal guardianUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
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* Date
Agreement & Release


Click here to read Camp Courage Agreement & Release full text.
* Signature of parent or guardianUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
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* Date
Emergency Contact Information

* Primary Contact Name
* Primary Contact Phone
Address
City
State
Zip
* Alternate Contact Name
* Alternate Contact Phone
* Physician Name
* Physician's Phone Number
Insurance Company
Insurance Policy Number
* Allergies (food, medical, etc)
Information Release Agreement


Click here to read Information Release Agreement full text.
* Signature of parent or guardianUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
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* Date
Prescott Outdoors Release and Acknowledgement of Risk


Click here to read Prescott Outdoors Release and Acknowledgement of Risk full text.
* Signature of CamperUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
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* Date
Parent/Guardian's legal responsibility for:
Parent/Guardian Name
* Date
* Signature of parent or gurdianUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
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