Summer Camp Special Needs Application Form

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Summer Camp Special Needs Application
A separate form needs to be submitted for Individual.
This form is to be used to notify the Allegheny Highlands Council of any special dietary, health, mobility or disability needs your
unit will have at summer camp. The Allegheny Highlands Council will make every reasonable effort to accommodate your special
needs. It is the responsibility of parents and/or adults attending to make sure the person has everything the person needs for
the time of the activity. This form will be submitted to the camp or activity personnel. Please be specific in explaining the needs
and attach additional sheets if necessary. The contact person you list below may be contacted if camp staff has any questions.
Please use a separate sheet for each individual requiring accommodation. Please submit this form by June 1.
Camp Name
Week Attending_______________________
_____________________________________________
Leader Name
_____________________________________________
Unit #_________ Council ________________
Last
First
Address
_____________________________________________________________________________________
Street
City
State/Zip
Day Phone:
_________________
Evening Phone:
_________________
Email: _____________________________
Name of person requiring accommodation:
Youth / Adult
______________________________________
Full Name
Circle one above
Parent / Guardian Name
Date: ______________
_____________________________________________
Day Phone:
Evening Phone:
Email: _____________________________
_________________
_________________
Please check those that apply.
CPAP Machine
Mobility
_Dietary
Allergies
Asthma
Other
Camp menus will be published at in May. If the menu doesn’t meet this person’s dietary needs
then accommodations must be met from home. See the reverse side for common special needs and assistance.
Please NOTE that Camp Merz has electricity available in Yahn, Rupert, Evergreen and Mead campsites for use with a
CPAP. Please bring a 100 foot grounded outdoor extension cord if you plan to use it in your tent.
List any additional information:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Parent / Guardian Signature:
Date: ___________
_____________________________________________

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