Full Name*

Nickname

I am 18 years of age or olderI am between 13 and 17. I will be supervised by my parent or guardian for the duration of the camp weekend

Gender —Please choose an option—FM

E-Mail Address*

Address

City

Zip code

Home Phone Number

Mobile Phone Number

Employer*

Primary Language*

Secondary Languages

List type of professional license held* : OTPTRNCNAMDStudentOther

If Other

Please initial if you will attend the weekend camp from Thursday afternoon until Sunday at noon:

We would like to accommodate you if we can so please let us know if you will require a late check-in or early check-out time.

How did you hear about Camp With A Ramp?

SCI and Volunteer Experience:

Do you have experience working with individuals with Spinal Cord Injuries?

Please give a brief description of your experience with Spinal Cord Injuries, your hobbies, interests, and areas of expertise; what you feel you can contribute to the camp weekend:

Please check the areas you are interested in volunteering:

Would you be willing to bring other individuals luggage in your vehicle to the camp weekend?—Please choose an option—YesNo

Would you be willing to give others a ride to the camp weekend in your vehicle? —Please choose an option—YesNo

Do you have any additional special considerations?

Medical History:

Do you have any of the following conditions?

History of heat related illness —Please choose an option—YesNo

Cardiovascular disease —Please choose an option—YesNo

Asthma or other respiratory problems —Please choose an option—YesNo

Are you hypersensitive to insect stings? —Please choose an option—YesNo

Do you have a condition that might be affected by volunteering for this weekend camp (i.e. heat sensitivity, change in altitude, etc.) —Please choose an option—YesNo (If yes, please explain):

List any allergies:

List any special dietary needs/restrictions:

Emergency contact 1* :

Phone number* :

Relationship* :