DEAR CAMPER

In order to provide you with the best possible holiday at Pioneer One Camp, it is important that the organisers know as much about your condition or disability as possible, so we know how much help and support you will need.

Please answer all questions in all sections as fully as you can, and then print the completed form using your browser's own [Print] option. If you need any help with completing any part of this form please contact the Camp Leader (details below) by e-mail or telephone:

E-mail to: Gillian_pioneer1@hotmail.co.uk, or
Telephone : Landline: 01249 464803 / Mobile: 07817 589387

Section 1a - Personal Details:

Your Full Name (req'd): Known as:
Address:
Postcode:
Date of Birth:
Weight: Height:
Contact Details:
Telephone: Mobile: E-mail:
Support Needs:




Section 1b - Next Of Kin Details:

Name: Relationship:
Daytime Tel: Evening Tel: Mobile No:
Address:
Postcode:




Section 2 - Personal Requirements:

The answers to the questions in this section will need to be shared with your helper(s).
Please select the options that best match your requirements:

Do you use a wheelchair?
What kind of wheelchair do you intend to bring to camp?
Can you walk?
Can you stand?
Can you manage transfers (e.g. to bed/toilet)?
Do you need assistance with toileting?
Do you need assistance with showering/bathing?
Do you have any problems with continence? *
* If Yes, how do you manage this?
Do you need assistance with dressing?
Do you need assistance with eating or drinking?
How do you communicate?
Do you have any problems with your vision? *
* If Yes, what difficulties do you have?




Section 3 - Doctor and Medical Details;

If you wish to discuss any aspect of your disability or support needs with the Camp Leader before you apply, please feel free to make contact by telephone or email as above.

Doctor's Name:
Address/Surgery:
Postcode:
Telephone:
Your NHS Number:
How do you communicate?
Do you have, or have you ever had any fits? *
* If Yes, how are these managed?
What is the nature/name and extent of your disability?
Are you allergic to anything (e.g. foods, medications, plasters etc.)? *
* If Yes, please give details:
Are there any specific instructions to be followed (e.g. no alcohol)? *




* If Yes, please give details:
Do you have any other conditions? (e.g. asthma, diabetes)? *
* If Yes, please give details:
Are you likely to need other medication on an “ AS NEEDED” basis ? *
* If Yes, please give details:
Do you have Learning Difficulties? *
* If Yes, do you need supervision with every-day care? (check all that apply) BathingShoweringBrush teethShavingOther
* If Other, please give details:

Is there any other medical information you would like us to know?

Please list all medications that are used on a daily basis and at what time they are to be administered ( all medication is administered by our camp nurse and all medication must be handed over to her on arrival)




Section 4 - Miscellaneous Details;

Can you sleep in a tent?
Must you sleep in our dormitory?
Do you follow any special diet (e.g. vegetarian, low fat, diabetic)? *
* If Yes, please give details:
Do you have a talent or an interest you would like to share at camp? Playing an instrumentOrganising an activityOther
* If Other, please give details:
Do you agree that any photo’s taken at camp can be used for publication and fundraising?

If there is anything else you can tell us about yourself that will help us make your holiday more enjoyable, please tell us below:



DECLARATION:

I the undersigned, agree that simple treatments may be carried out by the P1 Camp Designated Nurse, and that further medical assistance where required be gained at their discretion.

Signed:……………………………............ Date:…………………………..