CAMP ABLE Summer Camp Scholarship
Located in Pollock, Louisiana
APPLICATIONS DUE TO EASTER SEALS BY MAY 26th
What Is Covered:
Easter Seals Louisiana is proud to cover the full cost of camp tuition and the
application fees to Camp ABLE to approved children who are Louisiana
residents. Upon request, supplemental funds for travel costs can also be
provided if applicants meet the requirements. Spots are limited so get your
application in fast!
What Your Child Will Gain:
Through sessions at Camp ABLE it is our goal to provide a healthier, happier,
longer, and more productive life for children and adults of all abilities. After a
session at camp your child will return with:
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A renewed sense of independence
New friends
Confidence in their abilities
Stories to share with their friends at home
Athletic and emotional growth
To Apply for the Upcoming Summer Session:
*DO NOT MAIL THE APPLICATION TO THE CAMP DIRECTLY. YOU MUST SEND YOUR
APPLICATIONS TO US TO QUALIFY FOR AN EASTER SEALS LOUISIANA
SCHOLARSHIP.
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Complete the attached camp application and media release.
Include a recent photo of your child with the application
If you are applying for financial assistance for travel costs or other needs associated
with attending camp please include a short letter outlining your need and the estimated
costs.
Return application, photo, media release and financial need letter to Cathie Ruggerio no
later than May, 26, 2015. Documents can be emailed to [email protected] or
mailed to: 1010 Common St., Suite 2440 New Orleans, LA 70112.
Questions or concerns? Please call Easter Seals Louisiana at (504) 523-‐7325
2/27/2015
Camp Able @ Camp Hardtner Camper Application
Camp Able @ Camp Hardtner Camper
Application
This application must be completed by a parent or legal guardian. Please answer each question
as fully and honestly as you can. If you have questions or require assistance, please contact the
Camp Hardtner office @ 318-765-3794 or [email protected].
The cost to attend Camp Able @ Camp Hardtner is $460.
Each camper is required to have had a physical examination within the past 12 months. The
camper's primary care physician is required to sign a form that we will send after the camper is
accepted to a session.
* Required
Choose the session you are applying for: *
Please choose one session. Both sessions are for individuals ages 9+ with special needs.
Today's Date *
mm/dd/yyyy
Camper's First Name *
But my friends call me:
Camper's Last Name *
Camper's Email *
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2/27/2015
Camp Able @ Camp Hardtner Camper Application
Camper's Sex *
Male
Female
Camper's Age *
Camper's Height
Camper's Weight
Grade Completed *
Camper's T-Shirt Size *
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Adult XXX-Large
Camper's Address *
Camper's Address 2
Camper's City *
https://docs.google.com/forms/d/1L-bxmFcrLjIjAtBCrrPGeHmDNsWA4tFPHN_ZKvXw-Ac/viewform
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Camp Able @ Camp Hardtner Camper Application
Camper's State *
Camper's Zip Code *
Camper's Date Of Birth *
mm/dd/yyyy
The following section requires information for the Parent or Guardian (PG), as well as emergency
contact and alternate authorization.
PG First Name *
PG Last Name *
PG Email *
PG Address
PG Address 2
PG City
PG State
PG Zip Code
Main Phone Number *
(555.555.5555)
https://docs.google.com/forms/d/1L-bxmFcrLjIjAtBCrrPGeHmDNsWA4tFPHN_ZKvXw-Ac/viewform
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Camp Able @ Camp Hardtner Camper Application
Other Phone
Church and Church Location *
Emergency Contact Name *
Emergency Contact Phone *
Authorized Camper Pick up Name and Phone *
List all that apply. Camper's will not be released to anyone other than Parent/Guardian and those
listed below.
The following information is helpful in allowing us to get to know your camper and
assess the special needs your camper may require. Please be as descriptive as
possible. Thank you! *
What are his/her special interests?
https://docs.google.com/forms/d/1L-bxmFcrLjIjAtBCrrPGeHmDNsWA4tFPHN_ZKvXw-Ac/viewform
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2/27/2015
Camp Able @ Camp Hardtner Camper Application
What would he/she like to do at Camp Able?
How would you describe his/her disability?
What would you like your camper to gain by attending Camp Able?
If camper requires assistance eating, please describe specifically.
Does your camper use a wheelchair/walker?
https://docs.google.com/forms/d/1L-bxmFcrLjIjAtBCrrPGeHmDNsWA4tFPHN_ZKvXw-Ac/viewform
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2/27/2015
Camp Able @ Camp Hardtner Camper Application
If your camper requires assistance bathing, dressing, or with personal hygiene,
please describe specifically.
If your camper has difficulty communicating, please describe specifically.
If your camper does not eat a normal camp diet, please describe their special dietary
requirements.
If your camper has an allergies, please list the allergy(s) and treatment(s).
https://docs.google.com/forms/d/1L-bxmFcrLjIjAtBCrrPGeHmDNsWA4tFPHN_ZKvXw-Ac/viewform
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2/27/2015
Camp Able @ Camp Hardtner Camper Application
If your camper has any medical problems, please list problem(s), treatment(s), and
precaution(s) required.
If your camper has headaches, please list treatment.
If your camper is subject to seizures, please specify treatment and/or control
medications.
Describe any sleeping issue your camper may have and what needs to be done
should he/she wake in the night.
If your camper has any other difficulty, e.g. hearing, seeing, etc. please describe the
difficulty and assistance needed.
https://docs.google.com/forms/d/1L-bxmFcrLjIjAtBCrrPGeHmDNsWA4tFPHN_ZKvXw-Ac/viewform
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2/27/2015
Camp Able @ Camp Hardtner Camper Application
Is there anything else you are concerned about or information the Camp Able staff
should know about?
If your camper has attended Camp Able before, do you have a counselor request?
Other, please detail
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Camp Able @ Camp Hardtner Camper Application
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EASTER SEALS LOUISIANA MEDIA RELEASE FORM
I ______________________________________ the parent or legal guardian of
______________________________________ give permission for the use of my child’s
photograph or personal information to be used in promotional materials for Easter seals
Louisiana. This information may include: brochures, television spots, newspaper articles,
on air radio promotions, website, Social Media accounts (such as Facebook and Twitter)
and/or press releases.
I understand that these materials made by Easter Seals Louisiana, its employees and
agents are owned by Easter Seals Louisiana and that they may copyright them. I further
consent to allow Easter Seals Louisiana, their respective employees and agents, and those
acting with Easter Seals' Louisiana permission, to use my child's protected health
information, as defined under 45 C.F.R. 164.501, for the purpose of illustration,
broadcast, or testimonial in connection with any work of Easter Seals Louisiana and to
release this information to the general public.
Signature of parent or legal guardian:
___________________________________
Printed name of parent or legal guardian:
___________________________________
Child’s name:
___________________________________
Date:
___________________________________