You are on page 1of 6

Dear Friends of Silver Towers Camp, Enclosed is the application packet for the 2008 summer session.

Please review each document, complete and return with the non-refundable application fee. We encourage you to return the application packet as soon as possible to ensure the best opportunity for your camper to attend the sessions of his or her choice. Campers will be assigned based on age and ability levels and your preference selection. Campers may attend any of the sessions that reflect their age category. Special permission to attend a different session is possible by asking the director. Preference will be given to VT residents. All applications must be received no later than June 1, 2008 Check list of items to be mailed with completed application: 1. 2. 3. Completed Camper Application: Medical Form: must be completed and signed by approved licensed medical personnel. Application fee: $25.00 check/money order to Silver Towers Charities, Inc. required for each session.

Please call me: Incomplete application packets will not be accepted. Each packet must include items 1-3. Mail completed packet with application fee to: Earl Cavanagh 1116 US Route 5 East Dummerston, VT 05346 You will be notified of your acceptance and the session(s) you will attend

Camp Fees A non-refundable deposit of $25.00 for each session is required for all campers. Mail this deposit with your application form. This deposit must be paid separately for each camper. The cost of tuition for each week is $300.00 for all campers. The deposit may be deducted from the cost of tuition. The deposit must be paid before you receive notification of the camper’s acceptance and his or her session assignment.

2008 Silver Towers Camp Application
Name Social Security # Home Address Mailing Address Date of Birth Phone # City City Age Sex St. St. M Zip Zip F



Names of persons to be contacted in case of emergency Home Provider or Care Giver Address Parents or Legal Guardian Address

Phone # City Phone # City


St. Zip


St. Zip

Health Insurance Coverage Is the camper covered by family medical/ hospital insurance? Yes Medicare # Medicaid # ► Photocopy of front and back of health insurance card must be attached to this form


This section must be completed by the parent/guardian for camper’s attendance. Permission to Provide necessary Treatment or Emergency Care: I hereby give permission for medical personnel selected to order and approve various medical/treatment: to release any records necessary for insurance purposes; to provide/arrange necessary transportation for me/or camper in the event I cannot be reached in an emergency. I hereby give permission to the medical personnel to secure and administer treatment, including hospitalization for the person named above. I agree to abide by the restrictions as specified above during camp.

Signature of parent/guardian or adult camper Printed Name Date

Silver Towers will have eight one-week sessions. Each session will have approximately 60 campers, 30 males and 30 females. Each weekly session will be designed to meet the age, social and functional level of the campers. Two week stays or longer are available for those wishing to stay up to three weeks. Please indicate which session(s) you would prefer, with #1 being your first choice. Every effort will be made to place the camper in the session(s) requested whenever possible, however this cannot be guaranteed. Preference will be given Vermont residents.

Camp Fees are $300.00 per session for all campers. A $25.00 application fee must accompany each application.

2008 Camp Schedule
Session 1 Session 2 Session 3 June 22 to June 28
(ages 6-22)

Session 5 Session 6 Session 7

July 20 to July 26
(ages 23-70)

June 29 to July 5
(ages 6-22)

July 27 to Aug 2
(ages 23-70)

July 6 to July 12
(ages 23 - 70)

Aug 3 to Aug 9
(ages 23-70)

Session 4

July 13 to July 19
(ages 23-70)

Session 8

Aug. 10 to Aug 16
(ages 23-70)
Page 1

Camper Health Information Please describe any current health issues:

List any Allergies:

Heart or Blood Pressure Problems: Respiratory Problems: Diabetes: Skin Problems:

Special Diet: Seizure Disorder Controlled: Type: Frequency: Yes Yes Grand Mal No No Petit Mal


Does camper usually run a normal temperature? Is camper sensitive to sun? Is camper sensitive to bug bites Please list past significant medical histories:

Yes Yes Yes

No No No

Please list all medications and treatments (Dosage and times of administration):
Page 2

What best describes camper’s vision? Wears Glasses Is Legally Blind Normal Vision Blind Uses Speech Understands Speech Has Functional Vision

How does camper communicate with others? Uses Sign Language Understands Sign

Uses Adaptive Communication Device

What is the best way to communicate with camper? Behavioral Challenges: Indicate those that best describe camper: Aggression toward people Aggression toward objects Inappropriate Sexual Behavior Other Challenges not listed: What is the most effective way to deal with camper’s behavioral challenges?

Tantrums Manipulative Withdrawn

Self Injury Swears Non-Compliance

Hyperactive Poor Peer Relations

Does camper have specific behavioral procedures followed at home, school or day care program? Yes No

If yes, please describe: Describe campers Daily Living Skills: Independent Dressing: Bathing: Hygiene: Toileting: Eating: Bed-Making: Clothing Care: Does camper wet bed? If yes, how often? Yes No
Page 3

Needs Help

Needs Total Care

Please use this space to provide any further information that will help us better serve your camper:

Does camper have problems taking medicine? Best method to administer medicine:



Camper’s Physical Challenges Cerebral Palsy Paraplegia Walks assistance with Spina Bifida Ambulatory Muscular Dystrophy Uses Wheelchair Quadriplegic Uses Crutches

Camper’s Mental Challenges Developmentally Delayed Autism Emotionally Behaviorally Disturbed Down Syndrome Please List any other: Mild Mild Moderate Moderate Severe Severe

History of physical, mental, or sexual abuse:

Other: Camper’s Hearing Has Normal Hearing Is Hard of Hearing Has Functional Hearing Is Deaf
Page 4