Camp Adventure Summer Camp

Farmington Camp Canceled for the 2024 session

Albuquerque Camp is Full and not accepting anymore registrations at this time. If you want your child placed on a waiting list please contact Helen Pino at 505-301-4810

Camp Adventure is a summer adaptive camp for children 6 to 18-years-old living with permanent disabilities that receive care at Carrie Tingley Hospital. Camp Adventure allows children and teens the opportunity to unleash their possibilities!

During camp, campers enjoy sports like Sports chair basketball, laser tag, adaptive cycling, art, music, and games. Most importantly, they have fun and create lasting friendships and memories. Camp is staffed by qualified instructors and volunteers who provide instruction, encouragement, and support.

REGISTRATION FORM found below. We have limited space at the Albuquerque camp. Once we reach capacity we will initiate a waiting list.

QUESTIONS?

Contact Jennifer Bullock at JBullock@CTHF.net

GET INVOLVED!

VOLUNTEER

The Carrie Tingley Hospital Foundation is looking for youth volunteers, ages 16 and over, to assist with our Camp Adventure summer camps! Volunteers can work at one or more of the camps listed above. Camp activities will include wheelchair sports, archery, remote control cars, arts & crafts, adaptive cycling, and much more!

Albuquerque

Download the Volunteer Overview

CAMP ADVENTURE REGISTRATION FORM

Camp Adventure Registration Form 2024

Staff/Volunteers may have access to information about my child, which may be relevant to his/her participation in Camp programs. I understand that only necessary information will be disclosed and that all reasonable steps are taken to protect the privacy and confidentiality of my child's information.

CONSENT FOR DISCLOSURE OF INFORMATION

I do give my permission to the sharing of any relevant information between Carrie Tingley Hospital Foundation and program staff/volunteers.

I do not give my permission to the sharing of any relevant information between Carrie Tingley Hospital Foundation and program staff/volunteers.

First

Middle

Last

Age

Birth Date

Sex

Male

Female

Phone Number

Address

Apt/Unit #

City

State

Zip

Grade Level (2023-2024)

Name of School

Primary Diagnosis

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Other

Number in Household

Household income

Parent/Guardian Name

Phone Number

Alternative Phone Number

Address

Apt/Unit #

City

State

Zip

Email Address

Parent/Guardian Name - Required if Applicable

Phone Number

Alternative Phone Number

Physical Address

Apt/Unit #

City

State

Zip

Mailing Address (if different)

Apt/Unit #

City

State

Zip

EMERGENCY CONTACT INFORMATION

(if parent/guardian cannot be reached): Identification will be required if picking up/transporting Camper

Emergency Contact #1 Name

Emergency Contact #1 Phone Number

Emergency Contact #1 Relationship to Camper

Is Emergency Contact #1 Authorized to Pick up/transport?

Emergency Contact #2 Name

Emergency Contact #2 Phone Number

Emergency Contact #2 Relationship to Camper

Is Emergency Contact #2 Authorized to Pick up/transport?

INSURANCE

Please enter your child’s insurance information in the sections that follow.

If your child is not currently covered by medical insurance, you are required to sign release of liability for campers without medical insurance.

Name of Insurance Carrier

Policy #

Policy Holder

Group #

Insurance Phone #:

Child's Name

PLEASE ATTACH A COPY OF INSURANCE CARD TO THE APPLICATION

In the event of illness or injury, a reasonable effort will be made to contact you to obtain consent in advance of medical services being given to your child. If we are unable to contact you, CTHF Executive Director and/or Camp Director will consent to such services for your child by acting on your behalf, based on the written advance authorization below.

Copy of Insurance Card

Maximum file size: 3MB

AUTHORIZATION FOR MEDICAL SERVICES

Child's Name

I, the parent/guardian of ________________ have read the above statement regarding the authorization of emergency medical services in the event I cannot be reached. I designate CTHF Executive Director and/or Service Coordinator to authorize medical attention, hospitalization, and surgery as may be required in an emergency because of illness or injuries sustained by my child while participating in Camp Adventure. I hereby assume financial responsibility for hospitalization, medical attention, and surgery provided.

Medical Concerns and List Allergies

Please List all Medications (prescriptions/OTC) Including Dosage ( NOTE - CTHF Staff and Volunteers are not allowed to distribute any medication.)

Signature

Clear

Date

List of Services Received at Carrie TIngley Hospital and Clinics

Date of Last Clinic Visit

Other Medical Conditions

Allergies

Visual Impairments

Hearing Impairments

Learning Disabilities

Cognitively (Academically) Functions Below Peer Level

Please give details in the area below

Medical Condition Details

Cognitively (Academically) Functions Below Peer Level
What Level?

Immunizations Current?

Yes

No

(if no, please explain)

Does your child use any special equipment?

ACTIVITIES OF DAILY LIVING (ADL)

Does your child need assistance with Eating

Yes

No

Toileting

Yes

No

If yes, explain the assistance needed:

Does your child needs assistance walking from place to place
(I.e. needs a wheelchair, physical assistance, etc.)

Does your child have a catheter?

Yes

No

If yes, Is your child able to maintain catheter themselves?

Yes

No (please explain)

Please explain

Describe your child’s communication skills

Speaks clearly

Uses sign language

Speaks but may be difficult to understand

Uses communication board

Gestures

Other (please explain)

Communication Skills (Other)

Language(s) spoken/understood:

BEHAVIOR

Does the participant have any behaviors of which the staff need to be aware of?

Yes

No

If yes, please explain:

Are there certain behaviors that your child is working on at school/home that should be encouraged while at camp? Please explain.

What motivators (e.g., toys, activities, foods) will be strong reinforcers for your child?

Please list any triggers that might agitate your child. (e.g., loud noises, odd textures, etc.)

What is the best way to assist your child if he/she gets overwhelmed or upset?

Does your child have a Behavior Intervention Plan (BIP) or Individualized Education Program (IEP) at school?

Yes

No

Are there key actions, words, or phrases used to stop behavior and redirect?

Yes

No

If Yes, please explain:

Does your child follow directions?

Yes

No

Occasionally

If No, please explain:

Does your child have trouble with transitions? If so, how can I make transitions easier for him or her?

ADDITIONAL INFORMATION

Any specific activities to be encouraged?

Any specific activities to be discouraged?

Does your child use any special equipment?

With what might your child require assistance?

CAMP ADVENTURE

CONSENT FOR ACTIVITIES

I do

I do not

agree that my child is authorized to participate in any and all officially administered, sponsored or sanctioned activities at Camp Adventure, including, but not limited to: (1) Remote control cars ( Archery (3) Cycling (4) Supervised Climbing Wall, (5) Carnival and games, (6) Dance. (7) Ice Hockey (8) Indoor Laser Tag ( 9) Arts and Crafts (10) Sports chair basketball

Certain medical conditions may limit participation in specific activities and may require additional medical authorization from your medical provider and/or parent/guardian support.

CONSENT FOR MEDIA RELEASE & SPECIAL PERMISSIONS

I do

I do not

give my permission and approval the use of my child’s image, name, biographical information and/or audio recording to be used by Carrie Tingley Hospital Foundation as part of its fundraising efforts, advertising, publicity, promotion or any other use. I understand and agree that my image, information and/or audio recording may appear in any media now known or hereafter invented including but not limited to print materials, video, online presentations, or other media. I hereby waive any right to inspect and approve the uses to which it may be applied. Nothing herein will constitute any obligation on the Carrie Tingley Hospital Foundation to use any of the above rights.

D) GENERAL CONSENT

I agree that neither the Carrie Tingley Hospital Foundation nor its employees, agents, or volunteers associated with Camp Adventure shall be held responsible for any injuries or damages that occur while my child _______________ attends or participates in Camp activities. I do hereby hold harmless the Carrie Tingley Hospital Foundation/ Camp Adventure its employees, agents, and volunteers against any and all liability, damage, loss, claims or demands which arise out of or are in any way connected with my attendance or participation in Camp Adventure.

Child's Name

Parent/Guardian Name (Please Print)

Signature

Clear

Date

Captcha

Text

If you are human, leave this field blank.

Camp Adventure Summer Camp

GET INVOLVED!

CAMP ADVENTURE REGISTRATION FORM

Camp Adventure Registration Form 2024

EMERGENCY CONTACT INFORMATION

INSURANCE

PLEASE ATTACH A COPY OF INSURANCE CARD TO THE APPLICATION

AUTHORIZATION FOR MEDICAL SERVICES

ACTIVITIES OF DAILY LIVING (ADL)

BEHAVIOR

ADDITIONAL INFORMATION

CAMP ADVENTURE

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