SPECIAL NEEDS SUPPLEMENTARY INFORMATION
    Camper Information
    Camper’sName_______________________________Phone(____)______________
    Address: ____________________________________ Fax (____)_________________
    City: __________________State: ___________Zip: _________ Email: ____________
    Date of Birth (mm/dd/yy) _____/ _____/ _____ Age: _____ Male: ____ Female: ____
    Parent or Support Provider Information: Primary Contact
    Organization/Association __________________________________________________
    Street:___________________________________ Fax (____)______________________
    City:____________________ State ____ Zip________ Email______________________
    Are you away while the camper is at Hudgins:
    ?
    Yes
    ?
    No
    If yes, contact number and date(s) you will be away:____________________________
    Diet:
    Assistance at meal times
    ?
    Fully Independent
    ?
    Cut Food
    ?
    Uses Adapted Utensils (please provide)
    ?
    Other
    If other, please explain:________________________________________________
    Does the camper have any food allergies or other dietary restrictions that need to be monitored
    by staff?
    ?
    Yes
    ?
    No Please list any food restrictions or special dietary
    requirements.
    If camper is on a weight-loss program or has diabetes, please indicate what sort of
    snacks, desserts, etc. are allowed on the diet:___________________________________
    __________________________________________________________________________
    __________________________________________________________________________
    If a special diet must be strictly adhered to, please provide the meal plan.
    Daily Living
    Pleasedescribet
    henat
    ureofyourc
    hild’ss
    pecial
    needs:
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    Degree of disability: Check one
    ?
    Mild: performs all activities of daily living and self care with minimal or no assistance.
    ?
    Moderate: performs all activities of daily living, but at slow speed and with some assistance.
    ?
    High: Unable to perform all activities of daily living, requires constant assistance.
    Level of support recommended (please take into account the active nature of being at camp):
    Check one:
    ?
    Independent
    ?
    3 Campers: 1 Leader
    ?
    1 Camper: 1 Leader
    Does the camper have any physical limitations?
    ?
    Yes
    ?
    No
    ?
    Occasionally
    ?
    Constantly
    Does the camper require or use a wheelchair or mobility aid?
    ?
    No
    ?
    Occasionally
    ?
    Constantly
    If yes, please explain: __________________________________________________________________
    How does the camper communicate with others? _____________________________________________
    Pleasedescribet
    hecamper’ssl
    eephabits. __________________________________________________
    Assistance:
    Please indicate with: I
    –
    Independent
    V
    –
    Verbal prompting
    F
    –
    Full Assistance
    Dressing _____
    Deodorant _____
    Menstrual Hygiene _____
    Showering_____
    Shaving_____
    Incontinence Supplies_____
    Washing Hair_____
    Brushing Teeth_____
    Brushing Hair_____
    Using Toilet_____
    (Incontinence supplies sufficient to last entire time at camp must be sent with camper if needed.)
    School Setting
    Name of school: _______________________________________ Phone (____)____________________
    Name of teacher: _______________________________________ Grade: ________________________
    Does the child have an educational assistant?
    ?
    Yes
    ?
    No
    What type of learning environment?
    ?
    Segregated
    ?
    Integrated
    Howmanyst
    udentsar
    eihe
    nt c
    amper’scl
    ass
    ?__________
    Social/Recreation Considerations:
    Is your child acquainted with anyone else coming to camp?
    ?
    No
    ?
    Yes Who? _________________
    Has camper been away from home before?
    ?
    Yes
    ?
    No If yes, how long away from home? ________
    Where did the camper go? _____________________________________________________________
    Does the camper enjoy the water?
    ?
    Yes
    ?
    No
    Does the camper need a PFD?
    ?
    Yes
    ?
    No
    How well does the camper interact with others? ____________________________________________
    ___________________________________________________________________________________
    What type of activities does the camper enjoy? _________________________________________
    Does the camper participate?
    ?
    willingly
    ?
    with encouragement
    ?
    seldom
    ?
    No
    Does the camper have any significant fears?
    ?
    Yes
    ?
    No
    Please give details and describe how we can help with his or her fear: __________________________
    ___________________________________________________________________________________
    Behavioral Considerations:
    How often does the camper engage in behaviors that require our intervention?
    ?
    Frequently
    ?
    Rarely
    ?
    Never
    Describe the behavior: (please note severity, frequency, cause and early warning signs)
    ____________________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    How do you intervene when the camper engages in these behaviors?
    _____________________________________________________________________________
    _____________________________________________________________________________
    Have there been any behavioral changes in the past year?
    ?
    No
    ?
    Yes If yes, please describe:
    ____________________________________________________________________________________
    Is the camper on medication that controls or alters behavior?
    ?
    No
    ?
    Yes
    Does the camper use medication on an as needed or prescribed dosage basis to manage behavior?
    ?
    No
    ?
    Yes
    (Include details in the medication section of this form and ensure that the medication accompanies the camper to camp.)
    How does the use of the medication change the behavior? _____________________________________
    Does the camper use a behavior modification program?
    ?
    No
    ?
    Yes
    If yes, please outline on a separate page.
    Other Camper Information
    Please list any other information we should know in order to help us provide this camper with a
    safe, healthy and happy time while they are at camp.
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    I confirm that all the information on this form is accurate to the best of my knowledge. The camper is
    nonviolent and able to participate in a camp setting. The camper has been informed about camp and they
    have chosen to come to camp.
    I hereby give my consent for the staff involved to secure EMERGENCY care for
    ___________________________________________________________
    Name of Camper
    ________________________________________
    ______________________________________
    Parent/Guardian Signature
    Date
    ________________________________________
    ______________________________________
    Signature of person completing this form
    Date
    (If different from above)
    Please return this form prior to camp to:
    CrossTimbers Program Office
    3800 N. May Ave.
    Oklahoma City, OK 73112

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