Camper Application
(802) 247-6611 Camp Thorpe
680 Capen Hill Road
Goshen, VT 05733 		cthorpe@sover.net
Personal Information
Name:
 Date of Birth:
Address:
E-mail:
Camper Lives With:
Name:
Home Telephone:
 Work Telephone:
Cell Phone:
 Relationship To Camper:
Legal Guardian:
Name:
 Telephone:
Physician:
Name:
 Telephone:
Address:
Agency Contact (Mental Health, SRS, School, Other):
Name:
 Telephone:
Agency:
Address:
Insurance:
Medicare No.:
 Medicaid No.:
Other:
Health Information
Please describe current health problems:


Allergies:
Heart or Blood Pressure Problems:
Respiratory Problems:
Diabetes:
Skin Problems:
Special Diet:

Siezure Disorder? Yes No
Controlled? Yes No
Type: Grand Mal Petit Mal Psychomotor
Frequency:

Does camper usually run a normal temperature?
Sun Sensitive:
Bug Sensitive:

Significant past medical histories:


Medications and Treatments (Dosage and Time of Administration):


Problem taking medications?
Special way to give medications?
Physical Challenges
Indicate any that describe camper:
Cerebral Palsy Spina Bifida
Muscular Dystrophy Quadraplegia
Paraplegia Ambulatory
Uses Wheelchair Uses Crutches
Walks with Assistance
Other:
Mental Challenges
Indicate any that describe camper:
Developmentally Delayed:
Mild Moderate Severe
Autism:
Mild Moderate Severe
Emotionally Behaviorally Disturbed:
Mild Moderate Severe
History of physical, mental, or sexual abuse
Down Syndrome
Other:
Hearing
"Normal" Hearing Functional Hearing
Hard of Hearing Deaf
Vision
"Normal" Vision Functional Vision
Legally Blind Blind
Communication
Uses Speech Understands Speech
Uses Sign Language Understands Signs
Uses Adaptive Communication Device

What is the best way to communicate with the camper?


Behavioral Challenges
Indicate any that describe camper:
Aggressions toward people Tantrums
Aggressions toward objects Self Injury
Hyperactive Manipulative
Non-Compliance Swears
Poor Peer Relations Withdrawn
Inappropriate Sexual Behavior
Other:

What is the most effective way of dealing with the camper's behavioral challenges?


Does camper have specific behavioral procedures followed at home, school or day program?
Yes No
If yes, please describe (Use additional pages if necessary):


What are the camper's preferred activities and reinforcement?


Daily Living Skills

Independent Needs Help Needs Total Care
Dressing:
Bathing:
Hygiene:
Toileting:
Eating:
Bedmaking:
Clothing Care:
Does camper wet the bed? Yes No
If yes, how often?

Please use this space for additional information that will help us better serve your camper:


Financial Information
(Total is registration plus tuition charge.)
Applying for Session #:
Registration Fee: $100
(To secure placement. Non-refundable.)
Tuition: $600 ages 10-20 $700 ages 21 and older
(Includes program, 24 hour supervision, meals, lodging, nursing services.)

To secure placement for your camper, please return the completed application and registration fee.

The tuition is due in full on or before the opening day of the session. Campers will not be admitted if tuition is not paid in full.

Camperships - Financial assistance is available to qualifying campers to help meet tuition costs. If you feel you need a campership, please contact us at 802-247-6611 and we will discuss our eligibility requirements with you.
Additional Information
If necessary, can your camper receive the following over-the-counter medications while at camp?
Please check if yes:
Tylenol Advil
Benadryl Sudafed
Robitussin (cough) Pepto Bismol
Kaiopectate (anti-diarrheal) Milk of Magnesia
Tums Visine

During the course of the upcoming camping season one of the activities will involve campers making both a campus collage of pictures, as well as a more individual cabin collage of pictures. In order for this to be successful, we would like your permission to have your camper take part in an activity. Signing the statement that follows is an indication that you are aware of and give permission for your camper to appear in pictures that go home with other campers and that your camper has permission to appear in a camp-wide collage.
Parent/Guardian Signature:
 Date:

If you would be willing to have your camper appear in a Camp Thorpe brochure or video that might result from videos or pictures taken during this camping season, and which would be used only for the purpose of promoting Camp Thorpe, please sign below. Images may also be used on our website.
Parent/Guardian Signature:
 Date:

Another activity that occurs each year is tye dying. Campers have the option of tye dying one of the following items. Please indicate your preference:
A Camp Thorpe shirt (may be purchased at check-in time)
A shirt brought from home
Cloth provided by Camp Thorpe
Medical Release
Camper's Name:
 Camper's Social Security Number:
Camper's Legal Guardian:
Name:
Address:
Home Telephone:
 Work Telephone:
Who knows how to get in touch with you?
Name:
 Telephone:
Name:
 Telephone:
Name:
 Telephone:

Certification and Permission:
I certify that I am 's Legal Guardian.
(camper's name)

I give permission to Camp Thorpe to secure medical treatment in case of an emergency.

Guardian Signature:
 Date:

   

Dear Camper,

Thank you for requesting information concerning summer camping opportunities for the upcoming season. Camp Thorpe has devoted itself to helping children and adults with special needs find success in a summer camp environment. I hope that the information provided here is helpful in answering some of your questions.

The philosophy from which we function is a simple one."The purpose of Camp Thorpe is to help individuals leave a camping experience with good health, enhanced self-respect and respect for others, new leisure skills and an expanded respect for nature." Currently, camping experiences are provided to children and adults with a variety of physical and mental challenges. Camp Thorpe's tradition, created amongst the natural elements of the Vermont Green Mountains, provides these experiences to campers regardless of handicap or financial means. The original philosophy created a support structure that would enable the Camp to offer camperships for partial or full tuition for families or individuals meeting financial assistance requirements.

We are fortunate to have a fine physical facility which includes a craft house, a lodge, an infirmary, a large dining hall with a multipurpose room, cabins for campers and staff, a pool, pond, playground and tennis court. Trails through the surrounding woods lead to cabins that are used for picnic activities.

Please review the information above. It should be helpful in answering some of your questions. Also, you will find an application and relevant medical forms. (Medical forms are turned in prior to or at registration.) Do not hesitate to call me with any questions that you may have.

Sincerely,

Lyle P. Jepson
Director