2025 Camper Application

Attention: This form should be completed by the camper's caregiver. Please allow at least 30 minutes to complete and take your time to ensure all information is accurate.

We must receive your non-refundable camper application fee ($75) before your application can be considered. The cost of camp is $650 in addition to the camper application fee. You can pay online at the end of this form or you can mail payment made payable to CRC with the camper's name in the memo to:

Camp Rainbow Connection
11551 Lucks Lane
Midlothian, VA 23114

We will email you the medical form upon receipt of your application + fee. The medical form MUST be completed and signed by a physician.

Camper Information

Please complete this section with the CAMPER's information.

Camper's Preferred Name

Camper's Full Name

Camper's Address

Camper's Primary Phone

Available to text? Yes No

Camper's Birthdate

Camper's T-Shirt Size

Small Medium Large X-Large XX-Large XXX-Large 4X-Large 5X-Large

Primary Caregiver Information

Please fill out this section with the PRIMARY CAREGIVER's information. We know that many of our campers live independently or separate from their parent/guardian. The main caregiver will receive the confirmation email and information about camp.

If camper is their own caregiver, please provide contact information for person responsible for getting camper to camp.

Primary Caregiver's Name

Primary Caregiver's Address (if different than camper)

Primary Caregiver's Cell Phone

Available to text? Yes No

Primary Caregiver's Home Phone

This address will receive a confirmation email

I wish to be added to Camp Rainbow Connection's email distribution list to receive updates and prayer requests about members of the CRC community. Yes No

Parent/Guardian Information

Please complete this section with the GUARDIAN's information.

Parent/Guardian's Name

Parent/Guardian's Primary Phone

Parent/Guardian's Email

Physician Information

Please complete this section with the camper's physician information.

Physician Name

Phone

Address

I understand that my physician must complete and sign the medical form and that it must be submitted by May 1.

Yes No

Insurance Information

Insurance Company

Policy/Member ID

Group No.

Emergency Contact Information

Please provide us with 2 (TWO) individuals who can resume care in the event that you are out of town or are unavailable. If you are out of town, you must designate someone to be responsible on your behalf should your camper need to leave.

IN THE EVENT OF INJURY OR ILLNESS while in the care of Camp Rainbow Connection, I request the following to be contacted:

Emergency Contact Person 1 Name

Relationship to Camper

Cell Phone

Available to text?

Yes No

Home Phone

Work Phone

Address

Emergency Contact Person 2 Name

Relationship to Camper

Cell Phone

Available to text?

Yes No

Home Phone

Work Phone

Address

Consents

This camper has my permission to:

Attend Camp Rainbow Connection programming (i.e., community events and daily activities). I/We are fully aware that all activities are supervised by volunteer camp staff and that direct supervision around the clock is unattainable.

Yes No

I/We hereby authorize Camp Rainbow Connection staff to provide transportation when necessary in conjunction with activities conducted as part of the camp program or in the event of a medical emergency.

Yes No

I/We hereby authorize CRC to use any photographs or video taken of me or this camper for the purpose of publicity, promotion, or public information concerning CRC activities. Such use of images may include newspaper articles, brochures, magazines, slide or video presentations, press releases, television and displays. I/we understand that there may take photos of me or others and control over those situations is limited. Campers will be paid $1.00 for the use of their image at the end of the camp session.

Yes No

I/We hereby authorize CRC to use my/our name or that of my family member to accompany photographs or quotes for the purpose of promotion, publicity, or public information about the activities of CRC. Only the first name of campers will be listed.

Yes No

I/We hereby give permission for the nursing staff of CRC to provide basic medical attention and if needed, secure emergency medical attention for my camper.

Yes No

I/we further agree to be solely reliable for all expenses incurred for such emergency treatment. I understand that in case of non-life threatening medical issues which require immediate treatment, the Camp Rainbow Connection nurse will notify the guardians to come pick up their camper for transport to a physician.

Yes No

I/We attest that all information provided in application materials for Camp Rainbow Connection including the application, medical form, financial assistance request, and any supplemental items are true and correct to the best of our knowledge. I/We will review the camper rules and goals with this camper and understand that I/we may be required to resume caregiving roles should substantial behavioral concerns arise.

Yes No

Electronic Signature of Parent(s)/Legal Guardian(s):

Nature of Disability

Nature of disability and other medical information are necessary to match the camper and his/her staff buddy at camp. All medical and other information related to the camper's disability will be held in confidence.

If other, please explain:

Camper's Activities of Daily Living Profile

Please select one. This portion of the application is given to the volunteer buddy who will spend the week with your camper providing support and care. Please be thorough in your answers and explain what is needed for partial/total assistance.

Dressing

Explain:

Brushing Teeth

Explain:

Bathing/Showering

Explain:

Toileting (includes NO incontinence of urine or stool)

Explain:

Communicating

Explain:

Mobility (use aids for mobility?)

Explain:

Sleeping (please note that campers will be sleeping in a room alone)

Explain:

Camper Profile

Please help us help your camper make the most of their time at CRC. This portion of the application is given to the volunteer buddy who will spend the week with your camper providing support and care. Please be thorough in your answers.

What key verbal phrases work best with your camper when they need encouragement to follow directions or participate in activities?

Are there any verbal phrases that bring about negative behaviors from your camper when someone is giving directions?

What activities/routines specific to your camper do they perform before bedtime to help them sleep? (Example: this may include a required order in which they perform their self-care, listening to music, looking at books, coloring, etc.)

What key verbal phrases are used to encourage your camper to perform their bedtime self-care and for lights out?

Does the camper have difficulty with sleeping, bedtime or morning routines?

Please list all occasions, events, or stimuli that result in behavioral response from the camper. Examples of stimuli include sudden and loud noises, darkness, storms, new situations, and being told no.

Has the camper ever been to camp?

Yes No

If yes, where?

Does the camper participate in planned activities?

Never Seldom Often Always

Explain:

Violent Behaviors

A violent behavior is defined as any outburst that has occurred and results in injury of self and/or others.

Has the camper demonstrated any violent behaviors in the last 5 years?

Yes No

If yes, please describe.

When was the incident?

What happened? Please provide a detailed description.

Comments and/or concerns to share with the nurse or behavioral consultant and the leadership team that will help the evaluation of the camper's application?

Financial Details

I agree to submit my non-refundable $75 camper application fee before my application will be considered and understand that my application will not be accepted without receipt of payment.

Yes No

BE ADVISED: Some scholarships may be possible. All scholarship requests will be reviewed by a Scholarship Committee and approved only for campers that demonstrate a clear, documented need (to the extent funds are available). Please ensure you have fully explored all alternative sources of assistance.

I/We request an application for camper scholarship. I/We understand that we are not guaranteed financial assistance from CRC.

Yes No

If yes, I/we understand that we are not guaranteed financial assistance from CRC. Yes No

If you are seeking camper scholarship, please check other sources of assistance you will be exploring: Respite funds from Community Services Board Local Church Support Community Civic Group Sponsorship Family Support Other

I understand that the cost of camp is $650 in addition to the non-refundable $75 application fee and that I am responsible for submitting that payment at or before the start of camp.

Yes No

Payment: Credit Card/ACH Payment

You can pay online using a credit/debit/ACH transfer now. Checks should be made to CRC with the camper's name in the memo line and can be mailed to:

Camp Rainbow Connection
11551 Lucks Lane
Midlothian, VA 23114

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

July 13-18, 2025

Attention: This form should be completed by the camper's caregiver. Please allow at least 30 minutes to complete and take your time to ensure all information is accurate.

We must receive your non-refundable camper application fee ($75) before your application can be considered. The cost of camp is $650 in addition to the camper application fee. You can pay on this form or you can mail payment made payable to CRC with the camper's name in the memo to:

Camp Rainbow Connection
11551 Lucks Lane
Midlothian, VA 23114

We will email you the medical form upon receipt of your application + fee. The medical form MUST be completed and signed by a physician. Campers will not be accepted to camp until we have received a completed online application, application fee and medical form.

2025 Camper Application

Description

Please Fix the Following