Camp Application

Ranch Camp Application - 2004

**Camper Information:**
Last Name:		First Name:
Date of Birth :		Age at Camp:
Gender:	Male Female

Fees: $375 per session. $50 due with application. Balance due by June 1, 2003, unless other arrangements are made.

**Available Sessions**
SESSIONS	Dates	Ages Served
Summer Session 1	June 13-18	adults ages 23 & over
Summer Session 2	June 20-25	teens & young adults ages 13-22
Summer Session 3	June 27-July 2	all ages
Fall 1	October 15-17	all ages
Fall 2	Christmas Camp December 10-12	all ages

**Please indicate the sessions you wish your camper to attend according to preference.**
First preference?
Second preference?
Third preference?

**Parent or Guardian:**
Parent/Guardian Name:
Street Address:
City:
Zip:
Day Phone
Evening Phone
Mobile Phone
Fax
E-Mail

**Alternate Emergency Contact:**
Contact Name:
Street Address:
City:
Zip:
Day Phone
Evening Phone
Mobile Phone
Fax
E-Mail

Has Camper been to a residential camp before Yes
No

Does Camper want to attend camp? Yes
No

Please describe your Camper’s basic disposition:

**List any problems or concerns in the following areas, along with your suggestions on how to handle**
Sleep Patterns::
Suggestions:
Bathroom Habits:
Suggestions:
Diet & Eating:
Suggestions:
Dressing/Grooming
Suggestions:
Behavior Concerns:
Suggestions:
Fears:
Suggestions:
Communication:
Suggestions:

Notice: Ranch Camp is a residential camp designed for persons 13 and older who have: 1) mild to moderate mental retardation, 2) who are emotionally and physically well, and 3) whose behavior is within acceptable guidelines. If behaviors listed below occur with frequency sufficient to disrupt the normal function of the camp, they may result in a camper’s dismissal. Such behaviors include but are not limited to:

Wandering, running away Biting, scratching, kicking, fighting

Tantrums, foul language, cursing Self-injurious behavior

Refusal or inability to eat Refusal or inability to sleep

Persistent crying Willful destruction of property

Throwing objects Inability to adjust to camp life

Please note any history of these behaviors in the appropriate categories outlined above, no matter how long ago they may have occurred, and be prepared to discuss such incidents with Ranch Camp staff.

I affirm by signature below that the camper for which application is made meets the health and behavior guidelines described above. If 1) misrepresentation is made as to my Camper’s health or behavior, or 2) if the Camper becomes ill enough (including illnesses of psychosomatic origin,) or 3) engages in behavior deemed serious enough to warrant dismissal, he or she may be dismissed from Ranch Camp. I further understand that the return of the Camper home is my sole responsibility on the day I am notified, and that no refund will be made for the session from which the camper is dismissed due to health or behavior considerations.

Signature:_______________________________ Date:____________________________________

Consent to Use Likeness:

Indicate consent for myself/my child/my ward to be photographed, videotaped, or filmed, for use in proper interest of Down Home Ranch:

Give Consent

Deny Consent

Signature:_______________________________ Date:____________________________________

Print application and send with $50 deposit, which will be applied to total fee of $375 to: Down Home Ranch, Attn: Ranch Camp, 20250 FM 619, Elgin, TX 78621. You may also FAX this application to (512) 856-0256. To pay by credit card, fill out the form below:

**Enter Credit Card Information:**
Cardholder Name:
Amount this transaction:
Card Type
Expiration Date:
Card Number:

Note: No refunds will be made for sessions not attended unless notification is received prior to June 1, 2004. However, if a slot can be filled from the waiting list, a 75% refund will be made.

Wandering, running away	Biting, scratching, kicking, fighting
Tantrums, foul language, cursing	Self-injurious behavior
Refusal or inability to eat	Refusal or inability to sleep
Persistent crying	Willful destruction of property
Throwing objects	Inability to adjust to camp life