KAMP KALEIDOSCOPE SUMMER 2025 CAMPER APPLICATION

Once you submit your camp application, you will receive a copy of the registration by the email you indicated. (Check your SPAM/junk folder). Your camp spot will only be guaranteed once your reservation fee is paid. (REGISTRATION FEES ARE NON REFUNDABLE)

Prior to camp, you will receive further communication by email of documentation that will be needed upon arrival for camp.

Stay

Stay Full Week (5 day/4 nights) $600 Half Week (3day/2 nights) $300
Full week options

Full week options Week 1 - Adults - June 2nd-6th Week 2 - Kids - June 9th-13th Week 3 - Kids - June 16th-20th Week 4 - Adults - June 23rd-27th

Adults are 18 and older. Kids are 7 - 17.
Half week (Sessions)

Half week (Sessions) WK 1 Session 1 - M-W - June 2nd-4th WK 1 Session 2 - W-F - June 4th-6th WK 2 Session 3 - M-W - June 9th-11th WK 2 Session 4 - W-F - June 11th-13th WK 3 Session 5 - M-W - June 16th-18th WK 3 Session 6 - W-F - June 18th-20th WK 4 Session 7 - M-W - June 23rd-25th WK 4 Session 8 - W-F - June 25th-27th
Camper's Legal Name Camper's Legal Name First Middle Last
Camper's Preferred Name
Camper's Date of Birth: Camper's Date of Birth: / MM / DD YYYY
Camper's Age:
Camper's Gender:
Guardian's Name
Guardian Relationship - select only 1.

Guardian Relationship - select only 1. Self Parent Aunt/Uncle Grandparent Other Other
Guardian's email - Person submitting form and will receive all communication.

Person submitting form and will receive all communication.
Guardian contact # Guardian contact # - ### - ### ####
Guardian Mailing Address Guardian Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
SECOND CONTACT name for emergency only SECOND CONTACT name for emergency only First Last
SECOND CONTACT # SECOND CONTACT # - ### - ### ####

For emergency use only
SECOND CONTACT Relationship - select only 1.

SECOND CONTACT Relationship - select only 1. Parent Aunt/Uncle Grandparent Other Other
Does the camper have any of the following medical needs?

Does the camper have any of the following medical needs? Diabetes Seizures COPD Deaf/Hearing Impaired Blind/Visually Impaired Wheelchair/ Walker/ Cane Feeding Tube Other chronic illness or disability (PLEASE LIST BELOW)
CAMPER PROFILE

The following questions will aid in a successful camp for everyone.
Tshirt size for camper

Tshirt size for camper Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large Adult 2X Large Adult 3x Large Adult 4x Large
List any devices or aids to accompany camper:

If none just put none.
Does the camper have a diagnosis of Autism Spectrum Disorder?

Does the camper have a diagnosis of Autism Spectrum Disorder? Yes No

Campers do not have to have a diagnosis to attend camp.
List any other diagnosis:

Does the camper need assistance with the following
	Full Assist	Partial Assist	No Assist
Eating	EatingFull Assist	EatingPartial Assist	EatingNo Assist
Toileting	ToiletingFull Assist	ToiletingPartial Assist	ToiletingNo Assist
Showering	ShoweringFull Assist	ShoweringPartial Assist	ShoweringNo Assist
Dressing	DressingFull Assist	DressingPartial Assist	DressingNo Assist

List any aids needed for options above.

Please rate each of these pertaining to the camper:
	Normal	Mildly Affected	Significantly Affected
Hearing	HearingNormal	HearingMildly Affected	HearingSignificantly Affected
Speech	SpeechNormal	SpeechMildly Affected	SpeechSignificantly Affected
Communication	CommunicationNormal	CommunicationMildly Affected	CommunicationSignificantly Affected
Vision	VisionNormal	VisionMildly Affected	VisionSignificantly Affected

Can the camper sleep in a top bunk?

Can the camper sleep in a top bunk? Yes No
Things that help the camper sleep:

Things that help the camper sleep: Dark Room Fan Quiet Stuffed Animal, etc Medicine (please list) Medicine (please list)

Do these behaviors ever occur?
Do these behaviors ever occur?	Never	Seldom	Always
Biting	BitingNever	BitingSeldom	BitingAlways
Scratching	ScratchingNever	ScratchingSeldom	ScratchingAlways
Hurting myself	Hurting myselfNever	Hurting myselfSeldom	Hurting myselfAlways
Hurting others	Hurting othersNever	Hurting othersSeldom	Hurting othersAlways

Select triggers for these behaviors if applicable:

Select triggers for these behaviors if applicable: Noise Over question Placing demands on camper Forcing outdoor activities Other Other
If the camper becomes upset, what can we do to help the situation?
Has the camper ever made a suicide attempt or a threat to others to commit suicide? If yes, please explain.
Terms and Conditions for Reservations

All campers must submit a $200 registration fee for an entire week of camp ($100 registration fee for half week). This registration fee is non-refundable and cannot be used for other purposes besides registration. The camp fees can be paid online or by mail. Each camper is responsible for the balance of the camp fees by April 30th. If these fees are not paid, the reserved slot is considered vacated, and the slot is released to a camper on the waiting list.
Terms and Conditions for Participation

For and in consideration of The Center Ridge Outpost receiving the herin named camper in the camp, and in consideration of the same, and any services which might be performed for the camper, the undersigned, as natural guardian of said camper, for and on behalf of the camp or the undersigned individually, hereby releases, acquits, covenants to hold harmless and indemnify The Center Ridge Outpost, TEAAM, its staff and volunteers, and all other persons, firms, and corporations associated with them, from all claims, damages, actions, and causes of action of whatever nature which may accrue to the said camper or the undersigned, their heirs, executors, administrators, and legal representatives and assigns, arising out of any of the above procedures.
Draw or Type

I understand this is a legal representation of my signature and indicates agreement with the Terms and Conditions listed above. Clear

Full Name

I understand this is a legal representation of my signature and indicates agreement with the Terms and Conditions listed above.
Date Date / MM / DD YYYY
PAYMENT METHOD:
Registration fees must be paid for camper's spot to be reserved.

PAYMENT METHOD:
Registration fees must be paid for camper's spot to be reserved. Card Check Other Other

Specify
What are things I like to eat?
What are foods I WILL NOT eat?
Foods that I'm allergic to?

KAMP KALEIDOSCOPE SUMMER 2025 CAMPER APPLICATION

KAMP KALEIDOSCOPE SUMMER 2025 CAMPER APPLICATION

CAMPER PROFILE

Terms and Conditions for Reservations

Terms and Conditions for Participation