Spina Bifida Empowerment Camp 2019

Empowerment Camp Registration

Quantity
Price
Total
Camper with spina bifida

Fee for camper with spina bifida age 10 - 20 years.

X
$
60.00=
$
0

Sibling Camper

A single 10 - 20-year old sibling of a person with spina bifida may attend at the same affordable $60 camp fee.

X
$
60.00=
$
0

Additional Sibling Camper(s)

Up to 2 additional 10 - 20-year old siblings of a person with spina bifida may attend at the still affordable $100 camp fee.

X
$
100.00=
$
0

Final Total:
$
0

Information about Camper with Spina Bifida

Date of Birth
Camper Accommodations*

*Please provide basic information about your child's medications, means of mobility, bowel and bladder program assistance needed, transfer and dressing ability, food allergies and sensitivies, and any additional information that will be helpful in accommodating them at camp. You will be provided with a more detailed bowel and bladder schedule to complete along with additional camp forms prior to arriving at camp.

 

This year, nurse-assisted catheterizations will take place four times a day, before breakfast, before lunch, before dinner, and at bedtime. If your child is independent, and only needs reminders to self-catheterize, please note this here.

 

Bowel programs will take place either before breakfast or after dinner. A bowel and bladder management schedule will be included in camp forms and sent to SBCC prior to camp. This will be  reviewed with the camp nurses at check-in. Parents, campers, and nurses will also sign an agreement to adhere to this schedule as closely as possible. 

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*

Parent/Caregiver Contact Information

Parent/Caregiver Name
Address (if different than the camper with spina bifida)
Parent/Caregiver Phone Number (if different than the camper's)
Parent/Caregiver Email Address (if different than the camper's)

Sibling Camper Information

Please fill out the information below about each sibling camper so we make sure to accommodate everyone's needs.

Sibling Name
Sibling Birth Date
Sibling Gender
  • Male
  • Female
  • Other/Prefer Not to Answer
Sibling 2 Name
Sibling 2 Birth Date
Sibling 2 Gender
  • Male
  • Female
  • Other/Prefer Not to Answer
Sibling 3 Name
Sibling 3 Birth Date
Sibling 3 Gender
  • Male
  • Female
  • Other/Prefer Not to Answer

      

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

Security Code

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