“Texas Rowing For All”
Adaptive Summer Camp
Camper Information Form
Name:_____________________________________________ Today’s date:___________________
Phone #:_______________ E-Mail:___________________________________Birthdate:________________
Parent/Guardian/ Name_________________________ Phone______________ Email:_____________________
In case of emergency, whom should we contact: 1) __________________________ 2) __________________
Section I: General Questions
Describe your swimming ability:
What types of adaptations (if any) will you need during Camp?
Medical Information and History
Have you ever had any of the following? If so, please explain:
- Are you greatly affected by heat?
- Do you have allergies
- Do you have heart disease
- Do you have diabetes
- Do you have high Blood Pressure
- Do you have problems getting around (walking)
- Are you very sensitive to being in the sun?
- Do you have back problems
- Do you get cold easily?
- Are you taking medication? (*please explain—If yes, are there any side effects of the medication such as increased thirst, agitation, or fatigue—or other
- Are you allergic to insect bites or bee stings
- Do you have Seizures:
- If yes what triggers them?
- If yes, what is the date of you last seizure?
- Other Medical Concerns we should be aware of?
Describe your Disability:
Are there any “triggers” that we should be aware of with the Camper’s situation / behavior / other concerns? Please explain:
*So that we can better understand your needs, please list any medical, physical, psychological, or emotional issues not mentioned above:
What part about Summer Adaptive Camp are you looking most forward to?
What do you hope to get out of attending Summer Adaptive Camp?
Forms and Payment MUST be received by May 15, 2013
***Please complete and mail Camper Information Form & return with your Camp payment to:
Texas Rowing For All
5715 Bexley Court
Austin, Texas 78739