Download Report

CAMP GOT2GO APPLICATION FORM 2015
Please note that this PDF form is for preparation purposes only. You must submit your application online at
www.campgot2go.ca in order for your child to be considered. Please note that completion and submission of
this form does not guarantee that your child will attend Camp Got2Go. Crohn’s and Colitis Canada will conduct an
anonymous random draw of twenty (20) names for youth in Ontario and Quebec to attend camp at the Brigadoon
Village site in Nova Scotia, and (15) names for youth living in the Western Provinces to attend camp at the Easter
Seals Camp Horizon site in Alberta, plus an additional five (5) names for each site for the waiting list. There is also
an additional thirty (30) spots available at Camp Horizon for families who can provide their own transportation. If your
child is selected, Crohn’s and Colitis Canada will put you in touch with a camp coordinator from the host site. At this
point, Brigadoon or Camp Horizon staff will contact you to collect additional information and proceed with your child’s
camp application process.
Application deadline is 5 pm EST on May 1st, 2015.
Required sections are marked with an asterisk (*). You cannot submit your application without completing these
required fields.
There is a maximum file size of 20MB for all attachments combined. In order to complete this application, you
must upload three documents. Please ensure the total file size for these three documents combined does not
exceed 20MB.
Camper First Name:
Camper Last Name:
Date of Birth:
Gender:
Male
Female
Geographical Location
Western Canada
Can you provide transportation to
and from camp (For Western
Canada Campers ONLY)
Yes
School Name:
What is the camper's primary
language?
Quebec or Ontario
No
Grade:
English
French
Other
What other languages is the
camper comfortable
communicating in?
English
French
Other
Camper Street Address:
City:
Province:
Postal Code:
Home Phone:
Camper E-mail:
Parent/Legal Guardian Full
Name:
Relationship to Camper:
Parent/Legal Guardian Street
Address (if different than
camper):
City:
Province:
Postal Code:
Parent/Legal Guardian Home
Phone:
Parent/Legal Guardian
Cell Phone:
Parent/Legal Guardian E-mail
(please note, this is the e-mail
address that the confirmation email will be sent to):
Parent/Legal Guardian #2 Full
Name:
Relationship to Camper:
Parent/Legal Guardian #2 Street
Address:
City:
Postal Code:
Province:
Parent/Legal Guardian #2 Home
Phone:
Parent/Legal Guardian #2
Cell Phone:
Parent/Legal Guardian #2 E-mail:
In order to apply to Camp Got2Go, you must provide written proof of your child's Crohn's or colitis diagnosis, and
approval from your child's Gastroenterologist/GI Nurse that your child is healthy enough to attend camp. We may
contact your child's Medical Provider to confirm this information and request additional relevant information regarding
your child's health. This information will be kept strictly confidential.
I have read the above and I give authorization for Crohn's and Colitis Canada, or their partners at
Brigadoon Village or Camp Horizon, to contact my child's Medical Provider.
Yes
Medical Provider Contact Information:
Campers Gastroenterologist/GI
Nurse Name:
Hospital/clinic Name:
Office phone number:
E-mail:
Please ensure you submit a completed Medical Authorization Form with your application. Failure to include this
form will prevent you from submitting your application.
Please scan and upload a signed and completed Medical Authorization Form.
Upload Medical Authorization
Form here:
Select File
Please indicate your child's camp/overnight camp experience:
Attended day camp?
Yes
Attended overnight camp?
No
How did you learn about Camp
Got2Go (select all that apply)?
Medical Provider's office
Crohn's and Colitis Canada
Media
Internet search
Other
What prompted you to apply
(your interest, your child's
interest, something else)?
Yes
No
Please provide a brief summary (200 word maximun), in your child's own words, on why they would like to attend
Camp Got2Go. They can talk about their experience with Crohn's or colitis, what they are most excited about, etc.
Alternatively, encourage your child to draw a picture or create a short 30 second video message that can then be
shared with us. Please scan and upload your child's response/picture/video below:
Please upload here:
Select File
Please scan and upload a signed and completed General Authorization Form.
Please upload here:
Select File
Please be sure to submit your application before 5pm EST on May 1st, 2015. Applications submitted after
this date will not be considered. Once your application has been submitted, you should receive a
confirmation e-mail, along with a copy of the information you submitted.
Please ensure you have completed all required fields (marked with an *). Failure to complete mandatory
fields will prevent you from submitting your application.
Having difficulties? Please contact us at [email protected] and we will respond during regular office hours
(Monday-Friday, 9am-5 pm EST).