More Than Just A Camp!
Year round recreation for individuals with developmental disabilities.
P.O. Box 764 Mattoon, IL 61938 Phone (217) 895-2341  Fax (217) 895-3658

Website: www.campnewhopeillinois.org  E-mail [email protected]
Camp New Hope is pleased to announce that enrollment is now open for our 2017 summer camps!
Camp New Hope is also happy to announce that we can now accept diabetics who self-administer the insulin-pen. Please check with
us if your camper has other medical conditions, that may need special consideration to be accepted into camp.
Nestled on the banks of Lake Mattoon in Neoga in central Illinois, developmentally disabled children and adults have been enjoying
the myriad of activities Camp New Hope offers since 1974. Camp New Hope is a non-smoking facility open to special needs individuals who are ages 8 years old and above. Campers move around camp in a group ratio of 2:7 counselors to campers. Summer
camp consists of 7 weeks of overnight residential camp, 1 week of day camp, and new this year buddy camp. Camp also offers
Camper Care (Day only option) during the residential weeks of camp.
Many campers come back year after year, and enjoy all that camp has to offer. For campers, summer camp weeks are filled with
art, music, swimming, and recreational activities, all adapted to individual campers’ needs.
A three-foot swimming pool ensures safety while allowing campers to enjoy a cool dip on a hot afternoon. An amazing adapted mini
-golf course promises hours of fun, along with the playground, indoor cafeteria, asphalt trails and the Camp New Hope Train. Lake
Mattoon’s waters also bring the luxury of fishing, pontoon activities and the chapel area, which is a wonderful, serene place to gather. Evenings conclude with large group games, campfires, tournaments, and themed activities. Each Friday, camp week culminates
with an award ceremony allowing campers to show off their successes, and parents and family members to celebrate their camper’s
successes and experiences.
If you have a developmentally disabled loved one who might enjoy an experience at Camp New Hope this summer, please pass this
information along to them. It really is a life-changing experience for those who attend!
For more information, see the enclosed forms or our website www.campnewhopeillinois.org,
or contact us at 217-895-2341 or [email protected]
2017 Summer Camp Themes: Adventures Abroad
Week 1: June 4-9 (40+) Mount Everest & Asia
Week 2: June 11-16 (30+) Lost City of Atlantis
Week 3: June 18-23 (19-39) Land Down Under
Week 4: June 25-30 (21 & under) Russian Railway
Week 5: July 3-7 (DAY CAMP) America the Beautiful
Week 6: July 9-14 (40+) Brazilian Rainforest
Week 7: July 16-21 (19+) African Safari
Week 8: July 23-28 (All Ages/ 2nd Week Campers)
European Countryside
Week 9: July 30-Aug 2 (All Ages/ Buddy Camp)
Artic & Antarctica
Choosing the camp that is right for your family.

Residential Overnight Camp: Residential camp runs from Sunday afternoon till Friday afternoon. 7 Campers sleep in cabins
with their 2 counselors and participate in camp activities throughout the week. Weeks are designated based on age. Campers
can choose up to 2 weeks of residential camp, but we try to ensure every campers gets1 week of camp before guaranteeing the
second week.

Day Camp: Day Camp is for campers of all ages during the Fourth of July week. It is a great option for those who may not be
able to attend residential camp. Camp is Monday-Friday 9am-3pm each day including on July 4th. Camp New Hope provides
bus transportation from Mattoon and Charleston. Transportation may be available through RMTD for other nearby locations.
Please let us know if you are interested so we can give you more information.

Camper Care: Camper care is the Day Program Only option during residential weeks. This is a great option for a camper who
may not be ready yet for overnight camp or for campers who are looking to attend multiple weeks of camp during the day.
Campers signed up for this option can attend camp from 9am-5pm Monday– Friday (Friday pick-up is at 3pm.) and lunch is
included in the cost. Campers can sign up for as many weeks as they would like. Transportation to/from camp is not provided.

Buddy Camp: New to camp this year is Buddy Camp which runs from Sunday afternoon to Wednesday afternoon. Campers
can come with another camper, a friend, sibling, or someone else of their choice to accompanying them to this special week.
Buddies do not have to have a disability to come to camp. Buddy camp is open to all. Buddy camp may be cancelled if enrollment is not high enough.
OVER

More Than Just A Camp!
Year round recreation for individuals with developmental disabilities.
P.O. Box 764 Mattoon, IL 61938 Phone (217) 895-2341  Fax (217) 895-3658
Website: www.campnewhopeillinois.org  E-mail [email protected]
How to Register for Camp:
Registration Deadline:
April 1, 2017
All applications received after April 1,
is only as space is available, spots will not
be held without paperwork.
SAVE $25.00
Mail in or complete ONLINE (DO NOT FAX)
the 2017 Summer Camp Application Packet
By April 1, 2017
Please Note: Your application CANNOT be processed
if it is not accompanied by your deposit.
Wait for your confirmation for camp placement by mail
or e-mail. Confirmations will come out about every 2
weeks starting on March 1.
Early Bird Discount
If you have all your paperwork done
(Registration Form, Summer Camp Annual
Information Form, Health History signed by
doctor and are paid in full) before April 1,
2017, take $25 off your summer camp fee.
Send Application, Medical Forms,
& All Payments to:
In the meantime, schedule your camp physical
and have the physician complete and sign:
Health History Form
Due May 15, 2017
Final payment for your week of summer camp must be received
2 full weeks prior to your registered summer camp week.
Group Home campers MARS forms must be faxed
to: 217-895-2341 or emailed to:
[email protected]
Camp New Hope
PO BOX 764
Mattoon, IL 61938
Please make checks payable to
Camp New Hope
OR
Call the office at (217) 895-2341
Well Done!!
Your ready for camp!
www.campnewhopeillinois.org

CNH Camper Code of Conduct
(Please keep this form, and go over rules with your camper prior to coming to camp.)
Your counselors are responsible for knowing where the camper is at all times so the camper must:
Listen carefully and follow directions
Stay with your group—do not wander off by yourself.
Talk to your counselors if you need to go somewhere prior to going.
Never leave your cabin or group without a counselor.
Campers must be accompanied at all times- including middle of the night trips to the restroom.
Camp New Hope campers are expected to help one another including:
No hitting, kicking, spitting, biting, or anything else that might hurt another person.
No swearing or excessive yelling, name calling or bullying other campers.
Take care of your own clothes and respect other people’s property.
Helping to keep our camp and cabins clean and neat.
Enjoying everyone’s friendships—not just our special friends.
Camp New Hope rules also include:
Quietly waiting your turn for meals and other activities.
No campers may sleep on upper bunks.
No swimming without a counselor assigned and a lifeguard on duty.
All medications must be given to the nurses. Repeating ALL medications must be given to the nurses, including over the
counter medications.
No food or drinks are allowed in the sleeping areas.
Shoes must be worn at all times. Sandals must be sturdy and have an ankle strap. Flip Flops are allowed in shower only.
No Smoking
No sharp or dangerous objects.
No valuables—Camp New Hope is not responsible for lost or stolen objects.
Everyone must wear life jackets while in any camp boat and on deck.
Good personal hygiene is expected—including showers when scheduled.
Lights out is 9:30 P.M. This means campers are in bed and no talking.
Camp New Hope Song
(tune of John Jacob Jingle Heimerschmit)
Camp New Hope is my favorite camp,
It’s my camp and your camp too,
Whenever we are here, the campers always cheer,
Camp New Hope is my favorite camp, da da da da da
….
Superman Grace (Lunch Grace)
Thank you God for giving us food
Thank you God for giving us food
For our daily bread, For our daily bread
Thank you God for giving us food
God Our Father- (Breakfast Grace)
(Tune of Frere Jacques)
God Our Father, God Our Father
Once again, once again
We shall ask thy blessing, We shall ask thy blessing
Amen, Amen
The Johnny Appleseed Grace (Dinner Grace)
Oh the Lord is good to me, and so I thank the Lord,
For giving me the things I need,
the sun and the rain and the apple seed,
Oh the Lord is good to me.
OVER
ATTENTION ATTENTION ATTENTION ATTENTION
2017 Medication Procedure
PLEASE BRING ALL MEDICATIONS IN ORIGINAL PACKAGING!!
Routine Medication times at camp are 8:00 A.M., 12:00 P.M., 5:00 P.M., and 8 P.M.
*Please note: G-tube feedings are administered at Routine Medication times.
All medications will be scheduled for the closest time, unless contraindicated.
**NEW FOR 2017**
Camp New Hope is happy to announce that we can now accept diabetics who selfadminister the insulin-pen. Please check with us if your camper has other medical conditions, that may need special consideration to be accepted into camp.
All pills, tablets and capsules MUST be kept in the original packaging. i.e.: pill bottles, medication
tubes, bottles
ALL medications brought to camp must contain the original pharmacy labeled instructions.
Medications must all be written out on the provided medication form located on the 3rd page of the Annual Information Form.. A current Physician’s MAR may be included.
When arriving at camp make sure the drop off person knows about each camper’s medications. They will
be required to verify all medications, dosages, and administration times/methods.
Expired medications will not be accepted.
**MEDICATIONS NOT PACKAGED AND LABELED CORRECTLY WILL BE REJECTED**
Camp has lots of medications for each camper. Weekly Bubble Pack Medications are encouraged.
Check with your local pharmacies if they can take your medications and assemble them into a 1 week
bubble pack for your camper’s stay.
Additional Instructions for Group Home Campers Only
Please do not send new cycle meds. All meds should be on one card when in a bubble pack.
Please Do Not send medical tackle/ tool boxes. We do not have anywhere to store these.
Anyone residing in a Group Home MUST fax in or email their most current MAR at least 2 weeks
prior. Fax number is (217)895-3658. Email is [email protected]
Shampoo, toothpaste, mouth rinse and other hygiene items are not considered medications, and will need to be
sent in the luggage.
If questions arise prior to registration, please call Jill Rohr, Program Director at 217-895-2341.
Camper Registration Form for Camp New Hope, Inc. (2017)
Form must be filled out completely.
Camper Name: ____________________________ Preferred name, if any:_______________________
Date of Birth: ____/____/____ Gender:
Male
Female
Camper is own guardian
County: ___________________
Camper Address: _________________________________________ City: ___________________ State: _____ Zip: ___________
T-Shirt Size: circle one
Youth:
YS
YM
Does camper use any of the following: circle
YL
YXL
Adult:
Electric Wheelchair
AS
AM
AL
AXL
Manual Wheelchair
A2XL
A3XL
Walker/Cane/Crutches
A4XL
Leg Brace
Please send information for the following programs:
RESPITE Weekends (Aug-May)
BOWLING (Mattoon/Charleston)
HOLIDAY PARTIES (Halloween/Christmas/Easter)
Primary Parent/Guardian(s): Guardian who will be in custody during the camper’s attendance(s).
Relationship: _______________________
Name: _________________________________ Email Address: __________________________________
Camper lives here
Address: __________________________________________________ City: _________________ State: _____ Zip: __________
Home Phone:_________________________ Work Phone: _________________________ Cell Phone: _______________________
Secondary Parent/Guardian(s): Other guardian not living at same address as primary guardian(s) listed above. Relationship: __________________
Name: _________________________________ Email Address: __________________________________
Camper lives here
Address: __________________________________________________ City: _________________ State: _____ Zip: __________
Home Phone:_________________________ Work Phone: _________________________ Cell Phone: _______________________
Group Home: The facility/group that this camper is associated with.
Group Home Name: _________________________________ Home Contact: ________________________
Camper lives here
Home Address: __________________________________________ City: ___________________ State: _____ Zip: ___________
Home Phone:_____________________ Fax Number: _________________
QIPD Name: ________________________ Cell Phone: __________________ Email Address: _____________________________
Nurse Contact: has knowledge of camper medication. ______________________________ Phone Number: ________________________
Emergency Contact: Used only if guardian/facility is unavailable. Do not list name/number of someone already listed above.
Name(s): _______________________________________ Relationship: ____________________ Phone: _____________________
Who is responsible for paying the camper fee?
Parent
Self
Applied for Scholarship
Other (specify below)
Sponsoring Organization/Other : ________________________________________________________________________________
Address: __________________________________________________ City: __________________ State: _____ Zip: __________
Sponsor contact person: ________________________________________Sponsor Phone: __________________________________
(It is the parent’s responsibility to make sure that sponsor has made payment for your camper.
Please verify at least 1 month in advance of scheduled week.)
Cancellation and Refund Policy:
If a cancellation occurs 60 days prior to the beginning of the camper week, payments will be refunded, MINUS the
deposit. After this time, no refund will be given except as listed below:
 If cancellation occurs for a physician-documented medical reason all fees, MINUS the deposit will be refunded.
Or camper can choose a later week to attend camp if space is available.
 If during a session it is advised to send a camper home for medical reasons, the remaining portion of the session
will be refunded.
 No refunds will be made for late arrivals or early departures.
OVER
Camp Weeks: Please mark preferences
(R-Residential) (CC– Camper Care)
1st
2nd
Preference Preference
No
Preference
Check all that apply:
I want one week of RESIDENTIAL camp.
Week 1: June 4-9 (40+)
Week 2: June 11-16 (30+)
I want a 2nd week of RESIDENTIAL camp.
Week 3: June 18-23 (19-39)
I want the week of DAY CAMP. Check box
if you will be using Bus Transportation.
Mattoon
Charleston
Week 4: June 25-30 (21 & under)
DAY CAMP: July 3-7 (All Ages)
Week 6: July 9-14 (40+)
I want CAMPER CARE. (Day only option
during residential weeks) You may register
for as many CC weeks as you would like.
Week 7: July 16-21 (19+)
Week 8: July 23-28 (All Ages) 2nd Week Campers
Week 9: July 30-Aug 2 (All Ages) Buddy Camp
I want to attend BUDDY CAMP.
Due to the nature of camp, and the need to balance cabins based on campers needs, please choose the type of scheduling below.
STANDARD SCHEDULING: Camp will schedule camper with his/her age group and try to honor preferences.
SPECIAL SCHEDULING: Camp will do everything possible to specifically met these requests.
Date Request: Specific Week(s): _________________________________________________________
Reason: _________________________________________________________________
Buddy Request Name: (List no more than 2 buddies) __________________________________________________________
Request Same Week
Request Same Cabin
Request Same Day Unit
Requests NOT TO BE with this camper _____________________________ Reason_____________________________
Camp Fees Payment Calculation: (Local/Patron)
1st Week Residential:
$420
2nd Week Residential:
$420
Day Camp (July 3-7):
$185
Camper Care:
$185
x
___________ (number weeks)
Buddy Camp:
$320
per camper
Total Payment Due: (Must be paid 2 weeks before scheduled camp week.)
$_______________
$_______________
$_______________
$_______________
$_______________
$______________________
Deposit Submitted: (If applied for scholarship, only choose/pay Scholarship deposit)
Residential Deposit:
$50
x
___________ (number weeks)
Day Camp Deposit:
$25
Camper Care:
$25
x
___________ (number weeks)
Applied for Scholarship Deposit: $25
Total Deposit Due: (This amount must be paid with application.)
$_______________
$_______________
$_______________
$_______________
$______________________
Camper Balance: (Total Payment minus Total Deposit)
$______________________

Due 2 weeks prior to attending.
Early Bird Discount: (Subtract $25 from Camper Balance if all paperwork & payment is received by April 1, 2017)
Custodial Parent, Guardian or Participant (if own Guardian) Must Sign:
In signing this form, I hereby certify that the above information is correct. I give permission for the participant to
attend all camp activities including transportation of this participant in privately owned vehicles or public transportation for
approved out-of-camp activities.
I agree to any emergency treatment by physician or hospital in the event I cannot be reached. I understand that all
medication brought to camp must be clearly labeled as to content, administration times, and dosage.
I understand and assume all the risks associated with participation in an outdoor camping and aquatics program. I
relieve Camp New Hope, Inc. from all claims or causes of action arising from this camper’s participation.
I acknowledge that Camp New Hope, Inc. provides accident insurance for every camper; however, the camper’s own
family insurance is primary, and Camp New Hope’s is secondary.
I give permission to use the camper’s name and picture in publicizing the work and program of Camp New Hope, Inc.
I recognize the obligation of the Camp Director, in his/her absolute discretion, to terminate the camper’s stay at any
time due behaviors or medical conditions which might jeopardize the camper’s or others’ well being.
I will be financially responsible for any medical treatment that is needed for the participant.
I have read and understand the Camper Code of Conduct.
Signature_______________________________________________
Date________________________________
Relationship to Participant__________________________________________________________________________
Annual Information Form for Camp New Hope, Inc. (2017)
Form must be filled out completely.
All Important information relative to the camper’s health and well-being should be on
this annual information form. Please DO NOT rely on verbal instructions at the time of
check-in to communicate important information about your camper. Please remember
that even though your camper may have attended many times, their counselor may be
new and does not know about your camper and their required care. This information
helps us to provide the best care for your camper.
Camper’s Photo
Please use a CURRENT photo
(shoulder and up face shot)
of your camper. These will
be used for camper badges.
Camper Information
Camper Name: __________________________________________ Preferred name, if any:______________________
Age: _______ Date of Birth: ____/____/____ Weight: _______ Height: _______
Who does the camper live with? Check all that apply: Mom  Dad
Diagnosis: (Check & describe all that apply) Cerebral Palsy
Gender: Male

Other Family Member  Group Home
 Autism
Female
On Own
Down Syndrome
Intellectual Disability:  Mild  Moderate  Severe
 Speech Impairment:  Verbal
 Visual Impairment:  Blind
 Hard to Understand
 Some Sight
 Non-verbal
 Sign Language/Signs
 Communication Device
 Night Blindness
 Hearing Impairment:  Deaf  Some Hearing
 Hearing Aides
 Behavioral Disorder __________________________________
Mental Illness:______________________________________
 Physical Limitations: _________________________________
 Learning Disability: ________________________________
Other Disability: explain ___________________________________________________________________________________
__________________________________________________________________________________________________
Is this the camper’s first time attending Camp New Hope?
Yes  No
If no, did camper have any problems here:
__________________________________________________________________________________________________________
Has the camper ever been separated from his or her family before?
Yes  No
If yes, reaction and/or issues:
__________________________________________________________________________________________________________
Is homesickness likely to occur? Yes  No if yes, suggestions to ease the transition: _______________________________
__________________________________________________________________________________________________________
Does the camper attend school?
Yes  No
Is the camper employed? Yes  No
Will the participant stay with a group?
Where? _______________________________________________________
Type of Work? ________________________________________________________
Yes  No
Best way to get participant involved: ____________________________________________________________________________
__________________________________________________________________________________________________________
Favorite Activities (camp or home): _____________________________________________________________________________
__________________________________________________________________________________________________________
Situations that may cause fearfulness or upset: ____________________________________________________________________
__________________________________________________________________________________________________________
Mobility & Special Aides
Camper uses: (Check all that apply) Eyeglasses  Helmet
 Leg Braces
Wheelchair:
Gait Belt
Manual
 Hearing Aids
Dentures Walker
Crutches
Other Adaptive Equipment: ___________________________________________________________
Electric
Moves: Independently
Transfers: Independently  Standby Assistance  Pivot (1 person)
Swimming needs: Ear plugs  Nose plug Water shoes
 Lifejacket

Requires Pushing
Full Assistance (2 person)
 Steering
Hoyer Lift 
 Goggles
Page 1 of 4
Toileting & Showering
Uses Toilet Independently
Needs Reminders: ________________________________
 Able to tell you when needed.
 Needs Assistance (wiping, removing or putting on pants): _______________________________________________________
Has toilet schedule (explain): _______________________ Doesn’t use toilet at all: (depends, etc) _____________________
Uses catheterization or other adaptive devices: Describe: _______________________________________________________
 Menstrual Care:
 None
Showering:  Independent
 Needs Assistance with:
 Independent
 Needs Assistance: ____________________________________________________
 Needs Verbal Cues
 Adjusting Water Temp
 Needs Complete Assistance:
 Shampooing Hair
 Shower Chair
 Soaping
 Drying
 Shower Bed
 Brushing Teeth
Dressing
Is camper responsible for own belongings
Dresses Independently
Yes  No
Needs minimal assistance dressing
Needs total assistance dressing
 Describe assistance needed dressing: _______________________________________________________________________
 Describe any assistance needed undressing: _________________________________________________________________
Bedtime
Typical Bedtime: _______________ Awakes at: _________________
Does camper need a bedrail Yes  No
Sleeps: ________ hours a night
(Campers with active, regular seizures, requires a bedrail.)
If camper is non-verbal, how does camper typically sleep? (back, side, belly, with pillow, etc) _______________________________
_________________________________________________________________________________________________________
Does camper require special care during the night? Yes  No
if yes, explain: _____________________________________
_________________________________________________________________________________________________________
Does camper wet the bed at night?  Always  Sometimes
 Never
Does camper wear pull-ups to bed? Yes  No
Behavior and Communications
Any disruptive behaviors?  Yes  No If yes, describe: ___________________________________________________________
__________________________________________________________________________________________________________
Does camper respond to specific behavior techniques?  Yes  No If yes, describe: _________________________________
__________________________________________________________________________________________________________
Situations/Activities/Foods that can cause behavior problems? Describe:________________________________________________
Does camper usually comply with verbal requests/directions?  Yes  No
Does the participant verbalize clearly?
 Yes  No
If no, describe :______________________________________________
__________________________________________________________________________________________________________
Describe special Communications needs or instructions (sign language, special gestures, etc.): ______________________________
__________________________________________________________________________________________________________
Is there any possibility camper’s behavior would risk injuring self or others?  Yes  No
If yes, describe: ___________________
__________________________________________________________________________________________________________
Is the camper ever violent or dangerous to others?  Yes  No If yes, explain: _____________________________________
__________________________________________________________________________________________________________
Is the camper usually willing to share/take turns?  Yes  No
Does the camper tend to give up or become frustrated when confronted by challenging activities?  Yes  No
Please list any information concerning camper that would aid our staff in insuring their time at camp is safe and enjoyable: ________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Page 2 of 4
Meal Time
Typical Appetite is:
 Large  Typical  Small
Food Likes: _________________________________________________________________ ______________________________
Food Dislikes: ______________________________________________________________________________________________
Camper can use:  Fork  Spoon  Knife  Special Utensils, describe: ____________________________________________
Camper needs:  Food Cut  Sippy Cup  Straw  Food fed to them  Liquids Thickened (consistency): _________________
Other special instructions: _____________________________________________________________________________________
__________________________________________________________________________________________________________
Medication
Camper Name: _____________________________________________________________________________________________
How does the camper take medication?
Chews
With Liquid
Whole in food
Crushed in food
Other: ______________________________________________________________________________________________
If your camper has a need for over the counter medications during camp, dispensed on an as needed basis (PRN), such as: (Benadryl,
Anti-Diarrheal, Constipation, Heartburn/ TUMS, Cough Drops), please bring these medicines with you as camp does not supply
them to campers. Do not bring Tylenol or Ibuprofen; camp has these medications here.
The nurse has my permission to administer Tylenol or Ibuprofen to my camper, if needed. Yes  No initial ______
Circle Preference: Tylenol / Ibuprofen
Medications: List Current Medications, Dosage, and place check in Time for 8am
Administering. If other, write the specific time in the box.
Example: Metformin 500 mg, Take 1 tab twice daily
X
12pm
5pm
8pm
Other
PRN
X
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Put any additional medications on a separate sheet of paper
By signing below, I acknowledge that the medications listed above are correct at the current date listed below and that they may be
administered by the Nurse at Camp New Hope upon verification at check-in.
Signature of Responsible Person: _____________________________________________________ Date: ____________________
Page 3 of 4
Allergies:
Food Allergy?
If yes, describe in detail what the participant is allergic to and the allergic reaction.
Yes  No
Medication Allergy?
Yes  No
Insect Bite/Sting Allergy?
Other Allergies?
Carries Epi-Pen?
Yes  No
Yes  No
Yes  No
________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Special Dietary Needs/Restrictions:
Describe special dietary needs and special food preparation requirements.
________________________________
_________________________________________________________________________________
________________________________
________________________________________________________________________________
________________________________
________________________________________________________________________________
________________________________
________________________________________________________________________________
Seizures: Yes  No
Type of Seizures: ___________________________________________________________________
Frequency: ________________________________________________ Last Seizure Date: _______________________________
Aware of impending seizure? Yes  No
If yes, describe: _____________________________________________________________
Describe care required during/after seizure: _______________________________________________________________________________
_______________________________________________________________________________________________________________________
Other Medical Conditions:
Asthma  Communicable Disease Heart Condition G-tube Other Condition: _______________________________________
 Diabetes. Please Describe: No Meds Check Blood Sugar Daily
Oral Medication Insulin Pen
Vile Insulin

Please check if camper suffers from any of the following on a frequent basis:
Headaches
Migraines  Constipation
Problems Problems Sleeping
Diarrhea
Arthritis or Joint Problems
Stomach Disorders  Colds Skin
Please List any Activity Restrictions: _________________________________________________________________________
Medical Authorization/Permission to Treat Form for Camp New Hope, Inc. (2017)
Form must be filled out completely.
Medications
I, being the parent or guardian of (camper name)
, do herby authorize
appointed staff of Camp New Hope to administer all medicines, prescription drugs and other medical remedies required for or on
behalf of the above named person, while said person is participating in or at a Camp New Hope function.
I specifically agree to advise the staff and personnel of Camp New Hope of all prescribed and over the counter medicines which are
needed for the above named person.
Permission to Treat
I hereby give permission to the medical personnel selected by the staff at Camp New Hope, to provide routine health care; to
administer medications; to order X-rays, routine tests; treatment; to release any records necessary for insurance purposes; and to
provide or arrange necessary related transportation for above named person.
In the event of an emergency in which I cannot be reached, I hereby give permission to the Emergency Personnel or physician
selected by the staff at Camp New Hope, to secure and administer treatment, including hospitalization, for the above named person.
I further waive any claim on behalf of myself and the above named person pursuant to this authorization. I further warrant that I have
the authority to grant this medical authorization on behalf of the above named person. Furthermore, I agree to hold Camp New Hope
harmless by reason of my execution of this medical authorization and permission to treat.
This completed form may be photocopied for trips outside of Camp New Hope.
Signed:
Date:
(Signature of camper (if own guardian) or parent/legal guardian if other than parent)
Page 4 of 4
Healthy History Form for Camp New Hope, Inc. (2017)
Form must be filled out completely.
PARENT PORTION: Fill out top portion of form, and Return the ORIGINAL– DO NOT FAX. Information on this form is
gathered to assist in identifying appropriate care. Bottom portion must be filled out and signed by the doctor.
Camper Name: _______________________________________ Birthdate: ____________ Age: ________ Sex:
Male
Female
Contact Person: ______________________________ Phone: _______________________Alt. Phone: ________________________
Address: ___________________________________________________ Social Security Number: ___________________________
Does the camper have health insurance?
Yes
No
If so, indicate carrier: _____________________________
Policy #: _______________________________________
Please be aware that Camp New Hope does not have nursing staff on
duty from 10:00 p.m. – 6:00 a.m. During that time, 9-1-1 will be
called for any medical issues.
Parent/Guardian:
This health history is accurate, to the best of my knowledge, and the person herein described has permission to engage in all camp
activities (unless otherwise noted). I grant permission for camp personnel to administer medications as directed.
Signature of Parent/Guardian __________________________________________________________Date _____________
DOCTOR PORTION: Return this form to parent or
mail to Camp New Hope, PO Box 764, Mattoon, IL
Health History Check applicable history
 Frequent Ear Infections
 Heart disease/defect - Explain: ____________
______________________________________
 Seizure Disorder
 Diabetes
 Bleeding/Clotting Disorders – Explain: ______
_______________________________________
 HTN (High Blood Pressure)
 MRSA/VRE or Drug-resist infection:
Date cleared?__________________________
 Measles/Mumps/Chicken Pox
 Axonal/Cervical Instability
 Heat Sensitivity
 TB Test Positive
 Allergies: (Please list) ____________________
__________________________________________
__________________________________________
DME/Other:
 Foley Catheter
 G-tube/J-tube
 CPAP/Bi-Pap/Apnea monitor
 Other: _________________________________
Immunizations up to date?
Yes
No
Date of last Tetanus Vaccination: ______/______/______
If No, explain: _________________________________________________
Current Diagnosis: _____________________________________________
_____________________________________________________________
_____________________________________________________________
Pertinent History:
________________________________________
Diet:
 Regular
 Diabetic
 NCS/LCS
 Gluten Free
 No added Salt
Alterations:
 Pureed
 Mechanical soft
 Mechanical soft meat only
 Honey-thick
 Pudding thick
Food Restrictions/Allergies:
_____
________________
__________________
_________________________
___________
Does the camper have seizures?
Yes
No
What type? ___________________ Frequency _______________________
Are there any special treatments in addition to basic airway protection and
safety precautions? Explain
____________________ ____
_____________
____
_______________________________________________________
_______________________________________________________
Any other special restrictions or considerations should be written here: _________________________________________________
__________________________________________________________________________________________________________
Medical Provider Statement:
I have examined the above camper applicant within the past year on ____________________ (date of exam).
To my knowledge, the above named applicant has no conditions, including infectious diseases, which precludes his/her participation
in an active camp program (unless otherwise noted) and his/her immunizations are up to date. Medications may be administered as
stated by the guardian/parent/supervisor at check-in.
Licensed Provider Signature_________________________________________ Printed Name: ________________________
Address: ________________________________________________________ Phone: _______________________________
Date form completed: __________________________ by Physician, APN/ PA, RN/LPN