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Camper Application

If your child will be new to the Helen Diller Vacation Home, please fill out the preliminary application below and submit it to the camp Director for review.

Click Here to Download the Full 2012 Camper Application

Click Here to Download the Application for a Sighted Sibling

Parent Information

Name:

State:

Phone:

Email:

Camper Information

Name

Age:

Does your child require 1-1 assistance with daily living skills? (dressing, eating, bathing, toileting)

Yes

If yes, please explain the extend to which help is needed.

Does your child exhibit behaviors which require 1-1 assistance or which you feel would hinder the movement of his/her group?

Yes

If yes, please explain.

Does your child require medical assistance beyond taking medication on a daily basis?

Yes

If yes, please explain.

Are there activities in which your child cannot participate?

Yes

If yes, please explain.

What type of activities does your child enjoy?

Optional

Additional Comments

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