Confidential Camper Intake Form printable pdf download

Confidential Camper Intake Form

Please help us ensure that your camper has a successful summer experience by filling out this intake form.

This information is kept in STRICT CONFIDENCE. Please return this form to the CAMP OFFICE,

1301 Springdale Road, Cherry Hill, NJ 08003 no later than June 1st. Please feel free to discuss any of the

questions raised in this form with the camp staff at 856-424-4444 x 1242.

Camper’s name: ____________________________________ Sex: _____ Age________________ _

Name of parent /guardian completing form: _____________________________________________

Circle one:

Sun & Fun

KinderCamp

Camper age as of 7/1 (yrs/mo): _______ Bunk ________________

Parents’ marital status: _____ # of siblings in household: ________

1. Has your child had a summer camp experience before? ______ If yes, where? ______________________

2. Have there been any changes in the family situation in the past year (family move, separation, divorce,

death, new school, birth, etc.) What effect did it have on your child?

________________________________________________________________________________________

3. Is your child or the family receiving any special help with emotional concerns or behavior at school or

home (psychiatrist, counselor, social worker, etc.)?

________________________________________________________________________________________

4. Does your child have any allergies or health issues that we should be aware of?

________________________________________________________________________________________

5. Has your child been identified as needing support or supplemental services, during the school year, in any

of the following areas?

___academic ___personal/social ___language ___speech ___ OT ___health (i.e. - diabetes, peanut allergy)

___emotional (i.e. - anxiety, fears) ___ behavioral (i.e. - impulsivity, ADD/ADHD)

Please describe the nature of these services: ____________________________________________________

6. Does your child have an IEP or 504 plan? ____________________________________________________

7. Is there anything else you would like us to know about your child that will aide us in helping him/her have

a fun, well adjusted summer?

________________________________________________________________________________________

Do you have any specific concerns? Please explain:

Confidential Camper Intake Form