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 ---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?---YesNo

Would you be willing to give others a ride to the camp weekend in your vehicle? ---YesNo

Do you have any additional special considerations?

Medical History:

Do you have any of the following conditions?

History of heat related illness ---YesNo

Cardiovascular disease ---YesNo

Asthma or other respiratory problems ---YesNo

Are you hypersensitive to insect stings? ---YesNo

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

List any allergies:

List any special dietary needs/restrictions:

Emergency contact 1* :

Phone number* :

Relationship* :