Camper Application - 2025 Before completing this application, please read our Eligibility Requirements posted on our website. If you have any questions, please email us at acd@lionscamphorizon.orgCamper InformationFirstLastDoes your camper have a preferred name/nickname?Date of BirthGender Male FemaleDoes Camper reside with Parent/Guardian? Yes NoIf camper does not reside with parent/guardian please list contact information for who camper resides with.First NameLast NameGroup home or facility name if applicableMailing AddressAddress Line 1Address Line 2CityStateZip CodeRelationship to CamperPhone NumberEmail AddressPlease provide any additional informationShould all camp correspondence be sent to this address or parent/guardian? Address above Parent/GuardianFirst Name for Parent/Guardian #1Last Name for Parent/Guardian #1Parent/Guardian #1 Email AddressParent/Guardian #1 Phone/MobileFirst Name for Parent/Guardian #2Last Name for Parent/Guardian #2Parent/Guardian #2 Email AddressParent/Guardian #2 Phone/MobileParent/Guardian's Mailing AddressStreet AddressAddress Line 2CityState / ProvinceZIP / Postal CodeCountryCountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweCamper’s T-shirt size (all campers will receive a shirt as part of registration) Adult Small Adult Medium Adult Large Adult XL Adult 2X Adult 3XHas the camper attended Lions Camp Horizon previously: Yes NoIf so, please advise the last year of participation:How did you heard about Lions Camp?Has camper previously attended a different overnight/residential camp? Yes NoIf your camper is new to Camp Horizon and participated at another overnight camp, please advise the name and location of the camp and how your camper handled being away from home:PreviousNextPlease select ALL session dates your camper is available to attend camp. We will prioritize your 1 st and 2 nd choice but may need to look at other date options if those are not available. Please note Adventure Camp is subject to eligibility requirements. First time campers must attend Base Camp. Adventure Camp 1 - July 7-11* Base Camp 1 - July 14-18 Base Camp 2 - July 21-25 Adventure Camp 2 - August 4-8* First Choice:Adventure Camp 1 - July 7-11*Base Camp 1 - July 14-18Base Camp 2 - July 21-25Adventure Camp 2 - August 4-8*Second Choice:Adventure Camp 1 - July 7-11*Base Camp 1 - July 14-18Base Camp 2 - July 21-25Adventure Camp 2 - August 4-8*How many sessions would you like your camper to attend?Note: Our goal is to provide as many individuals as possible the opportunity to attend a camp session. Space is limited but we will make every effort to fulfill your request for multiple sessions.PreviousNextRegistration Deposits: A $50.00 non-refundable deposit is required of private-pay campers for each session requested. The deposit is not required of campers using DSHS/DDA funding. Campers using DSHS/DDA funding must have respite hours and payment pre-approved by their Case Manager before we will hold session dates. We will submit a pre-authorization request to DSHS/DDA but it is the Parent/Guardian’s responsibility to follow-up and ensure we receive it within 14 business days of the request. Camp Session Payment Method: Private Pay Respite Benefits – DSHS/DDAPlease provide information for the person responsible for paying.First NameLast NameEmail AddressPhone numberPlease provide your Case Manager's information below.Note: Your Case Manager’s e-mail address is required for securing your camper’s pre-authorizations. Applications cannot be processed without the Case Manager’s valid email address.First NameLast NameEmail AddressPhone numberEmergency Contact InformationIf you will not be available via phone for questions regarding behaviors, illness, dietary restrictions, etc., or if youwill not be available to come pick up your camper due to illness, behaviors, or emergency, please provide the name and contact information for the person we should contact and/or release your camper to. This person will also be contacted if we have made multiple attempts to reach you, but are unable to get in touch.Emergency Contact #1 Name:Emergency Contact #1 Relationship:Emergency Contact #1 Cell Phone:Emergency Contact #2 Name:Emergency Contact #2 Relationship:Emergency Contact #2 Cell Phone:PreviousNextPersonal InformationIt is crucial that the information provided below is accurate and as detailed as possible. This ensures your camper, and our staff, have everything they need for a safe and enjoyable camp experience. If there is anything we should know that isn't addressed in the following questions, please add notes or contact us at acd@lionscamphorizon.orgMobility (select all that apply) Walks/runs independently Needs assistance walking/running Needs assistance with steps Uses a cane Uses a walker Uses a manual wheelchair Uses a motorized wheelchair Wears AFO’s or braces on legs Requires a gait belt Prone to fallingPlease provide more details about "Needs assistance walking/running."Please provide more details about "Wears AFO's or braces on legs."Please describe transfer process and level of assistance needed.Please provide more details about "Requires a gait belt."Please provide more details about "Prone to falling."Activity LevelActivity level (select all that apply) Has typical attention span Has short attention span Easily distracted Is hyperactive Will participate in most activities Refuses to participate/ prefers to watch Is underactive (needs motivation) Stays with group Wanders from group or is a “runner”Please provide more details about "Has short attention span."Please provide more details about "Easily distracted," and strategies to redirect.Please provide more details about "Hyperactive," and strategies to redirect.Please provide more details about "Underactive (Needs Motivation)," and strategies to redirect.Please provide more details about "Wanders from group or is a 'runner,'" and strategies to redirect.What are some favorite activities?What are some LEAST favorite activities?Clubs are being offered this year. Please select any that your camper would be interested in: Relaxation/Spa Arts and crafts Sports Sensory play Science experiments Games (digital or classic) Movies Cooking/baking Exploring nature MusicCare Needs (select all that apply): Has good fine motor skills Has poor fine motor skills Needs hand over hand Sensitive to loud noises Sensitive to flashing/ twinkling lights or disco ballsPlease provide more details about "Has poor fine motor skills."Please provide more details about "Needs hand over hand."Please provide more details about "Sensitive to loud noises." Please specify if they use headphones or earplugs. Include any additional details.Hygiene and personal care (select all that apply) Uses toilet independently Uses a toilet on a schedule Requires assistance using the toilet Does not use toilet at all; uses incontinence briefs Requires being woken at night to use the toiletPlease provide schedule/usual times.Please provide more details about "Requires assistance using the toilet."Please provide more details about "Does not use a toilet. Uses incontinence briefs."Showering (select all that apply) Can shower independently Needs assistance adjusting water Needs verbal cues during shower Needs assistance shampooing Needs assistance soaping Needs shower chair or bench Needs complete assistance in the shower Prefers evening shower Prefers morning showerPlease provide more details about "Needs verbal cues during shower."Please provide more details about "Needs assistance shampooing."Please provide more details about "Needs assistance with soaping."Please provide more details about "Needs complete assistance in the shower."How frequently does your camper shower?Please provide any additional details to help with personal hygiene and toileting.Dressing (select all that apply) Has no difficulty dressing Needs some assistance with dressing/undressing Needs total assistance with dressing/undressing Needs assistance choosing clothes Needs assistance tying shoes Needs assistance with buttons/snaps/zippers Needs assistance with beltPlease provide more details about "Needs some assistance with dressing/undressing."Please provide more details about "Needs total assistance with dressing/undressing."Please provide more details about "Needs assistance choosing clothes."Please note any other dressing needs we should be aware of.Sleep (select all that apply) No sleep issues Light Sleeper Heavy Sleeper Snores Uses CPAP or VPAP Needs a night light Sleep walks Sings/cries at night Needs to be woken up to use the toilet Needs bed checks for incontinence Has trouble falling asleep or staying asleepPlease provide more details about "Uses CPAP or VPAP." Do they need assistance with this?Please provide more details and/or strategies used for "Sleep walks."Please provide more details and/or strategies used for "Sings/cries at night."Please provide more details about "Needs to be woken up to use the toilet."Please provide more details about "Needs bed checks for incontinence."Please provide more details about "Has trouble falling asleep or staying asleep."Please provide usual bedtime and usual wake-up time:Please provide any schedule or other information that may be helpful with camper's night routine. Communication (Select all that apply) Verbal - no communication issues Uses only single words Uses complete sentences Non-verbal Mute Comprehends 2-3 words Comprehends complete sentences Gestures/points Stutters Uses PEC board Uses Sign Language Uses an AAC device Writes to communicate Hearing impaired Uses hearing aidsPlease provide more details about "Uses only single words."Please provide more details about "Non-verbal."Please provide more details about "Mute."Please provide more details about "Comprehends 2-3 words."Please provide more details about "Gestures/points," and note common gestures used.Please provide more details about "Uses sign language."Please provide more details about "Uses an AAC device."Please provide more details about "Hearing impaired."Please provide any other communication challenges, styles, and strategies that may be helpful.Behaviors (Select all that apply) Does well in large groups (12 or more individuals) Does well in small groups (fewer than 12) Prefers to be alone Sensitive to touch from others Touches others - Hugging, poking, tapping Quick to anger Easily frustrated Uses profanity Verbal outbursts Throws objects Defiant behaviors Exhibits Obsessive Compulsive BehaviorsPlease provide more details and/or strategies for "Touches others - Hugging, poking, tapping."Please provide more details and/or strategies for "Quick to anger."Please provide more details and/or strategies for "Easily frustrated."Please provide more details about "Uses profanity."Please provide more details about "Verbal outbursts."Please provide more details about "Throws objects."Please provide more details and/or strategies about "Defiant behaviors." Please list specific behaviors and strategies related to "Exhibits Obsessive Compulsive Behaviors."Does your camper have a history of physical or verbal aggression? If so, please provide triggers/circumstances and re-direction/de-escalation techniques used to calm your camper. Has your camper been charged or convicted of a crime? Yes NoPlease provide more details.We periodically have volunteer groups bring horses for riding, therapy animals or "guests' from a petting zoo. Please let us know:Is your camper afraid of animals? What kind?If your camper is allergic to any animals, please specify the type, reaction, and the severity.PreviousNextMedical Information(to be completed by parent or guardian, not physician)These are general medical questions, a Health Examination Form will be provided for your camper's Doctor or Nurse Practitioner to complete.Camper’s Primary Diagnosis:Secondary Diagnosis:Chronic Medical Conditions: Does your camper have seizures? Yes NoPlease list type, frequency and date of last seizure.Do they have a written behavior plan in place? Yes NoNote: We may ask for a copy via emailDoes your camper have any of the following: Urostomy Bag Stoma/Colostomy Bag Catheter Insulin Pump CPAP or BiPap Machine Prosthetics Medical or Cochlear Implants Hearing Aids Dentures Feeding Tube Not ApplicableUrostomy Bag - What level of assistance and daily care do they need with this?Stoma/Colostomy Bag - What level of assistance and daily care do they need with this?Catheter - What level of assistance and daily care do they need with this?Insulin Pump - What level of assistance and daily care do they need with this?CPAP or BiPap Machine - What level of assistance and daily care do they need with this?Prosthetics - What level of assistance and daily care do they need with this?Medical or Cochlear Implants - What level of assistance and daily care do they need with this?Hearing Aids - What level of assistance and daily care do they need with this?Dentures - What level of assistance and daily care do they need with this?Feeding Tube - What level of assistance and daily care do they need with this?Please list any other devices or equipment your camper has and what level of assistance is needed.Effective January 2024, Camp Horizon requests all medications are pre-packaged in Bubble Packs or Simple Dose Packs if your pharmacy provides this service.If your pharmacy does not provide this service, please ensure all medications are in the original pharmacy bottle. This must include the campers name, medication name and dosage instructions. Over the counter medications, supplements, ointments, etc., must be listed on the Health Exam Form completed by a physician. All medications and dosages must match the Health Exam Form.Please list ALL current medications with DOSAGE & TIME medication is administered (Morning, Mid-Day, Evening, As Needed)Dietary Restrictions:Our kitchen staff must accommodate a wide range of medically required dietary restrictions and food allergies. We must distinguish between essential dietary restrictions and personal preference. We cannot accommodate personal preference. Please only list restrictions that are medically diagnosed/prescribed and not personal preference. The Health Exam Form must list these restrictions and/or allergies. We offer a variety of options at each meal for those with a limited selection of foods they will eat. Please reach out to acd@lionscamphorizon.org with additional questions or concerns regarding dietary needs.Has the applicant been diagnosed by a physician with a dietary condition such as Celiac Disease, PKU, Diabetes, food allergies, or any other condition? If yes, please list the condition and give a detailed description of dietary restrictions and reactions. Any dietary conditions or restrictions must be listed on the Health Exam Form by the physician.Does the applicant have special dietary requirements ordered by his/her Doctor or Nutritionist? (Select all that apply) None Lactose/Dairy Free Gluten Free Vegetarian Sugar Free Peanut Allergy Pureed Food Food Allergies Other (please specify)NOTE: We may not be able to accommodate severeallergies or some dietary restrictions. These will be addressed on a case-by-case basis toensure the health and safety of your camper.Lactose/Dairy Free - Please explain the severity, reaction, and details of the restriction.Gluten Free - Please explain the severity, reaction, and details of the restriction.Vegetarian - Please give more details.Sugar Free - Please explain the severity, reaction, and details of the restriction.Peanuts - Please explain the severity, reaction, and details of the restriction.Pureed Foods - Please give more details.Food Allergies - Please explain the severity, reaction, and details of the restriction.Other dietary requirementsPreviousNextWhat's Next?Submitting your application:Your application has not been submitted yet. Please continue reading to complete the consent form and submit your application for review. Thank you for completing your application! Our Admissions Team will review your application and be in touch soon. We may reach out with additional questions or request additional information. Once the review is complete, you will be advised of the session date(s) we are holding for your camper. These dates are subject to change and subject to the completion of all requested documents and payment. Payment:DSHS/DDA Funding:All DSHS/DDA payments will be pre-authorized by our admissions team. (Do not send a deposit) We will process the necessary paperwork in accordance with their policies and procedures. We may reach out if additional communication/information is required by your case worker. Private Pay:A $50 deposit is due at the time of acceptance to hold your space for each camp session. We will send an invoice to the person listed on the application as the billing contact. Payments can be made on the remaining balance, or you can pay in full. Final payment is due no later than June 7, 2025.Deposits and payments may be paid by check, debit or credit card. Mail checks payable to Lions Camp Horizon to 7506 Gemini St., Blaine, WA 98230. To pay with a debit/credit card, please visit our website and click on the “CAMP” drop-down box located at the top of the home page. Click on “Fees” and follow the prompts to access our secure PayPal link. Please note - PayPal charges a fee for each transaction. Forms:You will receive a Health Exam Form via email to be completed by the campers Physician. It is important this form is completed as soon as possible. Reviewing the Health Exam Form is an important step for final approval and securing a space at camp. All camp spaces are “pending” until the receipt of all forms, payment and/or DSHS/DDA approval is completed. Please review and sign the consent form below.Parent/Guardian Consent FormCamper Name:Photo/Video Release: Designated staff members take photos of events and activities. Some of these photos may be focused on your camper, or they may be in the background. It is our intention that all photos are a positive reflection of your camper. Photos are posted on our social media during camp sessions to provide families/caregivers with a glimpse into camp life. They may also be used in promotional materials such as brochures, flyers, and website photos. Do you give Lions Camp Horizon permission to use photos and/or video that may contain images of your camper? Yes NoConsent to Participate:I give permission for the above-named camper to participate in Lions Camp Horizon activities both on-site and off-site. The activities include, but are not limited to, riding in go-karts or other recreational vehicles, water activities, archery, field games, inclusive sports, bowling, arts & crafts, talent shows, dances, etc. They may also participate in animal activities which may include horseback riding/wagon rides, animal interactions/petting. All animals will be under the supervision of a handler. I understand precautionary measures are taken to safeguard the safety of my camper and agree to hold harmless volunteers and outside agencies who provide entertainment and activities during camp sessions. I acknowledge appropriate safety equipment will be provided as needed and criminal background checks will be completed on any staff members or volunteers who work with my camper.Consent to Transport:I authorize Lions Camp Horizon to transport my camper to/from off-site activities using rented vans, WTA buses and/or private vehicles. I acknowledge drivers will be subject to background checks and must provide proof of insurance and a clean driving record.Consent to Discharge Camper:The safety of our campers and staff is our top priority. Any campers who do not follow health and safety guidelines will be asked to go home immediately.I acknowledge my camper may be discharged if he/she engages in any of the following: Hits, grabs, bites or is overly aggressive towards a camper, staff or volunteer Inappropriate touching or sexual behaviors Verbally abusive or uses inappropriate language/gestures Theft or deliberate property destruction Inappropriate behavior with guest presenters oranimals Violates our zero-tolerance policy on tobacco, vaping, alcohol or drugs Unable to sleep in dormitory setting or disrupts other camper’s sleep. Emotional outburst, tantrums or refuses to participate at a reasonable level. Unwilling to comply with health and safety protocols such as handwashing, proper hygiene, wearing protective safety equipment during activities (Head gear, safety glasses, seatbelt, life jacket, etc.) Develops a fever over 100 degrees, has symptoms such as nausea, vomiting, diarrhea. Shows any signs of a contagious condition. I understand that Lions Camp Horizon will make every effort to correct behaviors and encourage appropriateinteractions/redirection before discharging my camper. I agree to make immediate arrangements to remove my camper if asked to do so. By E-signing you agree to the terms above. If you have any questions, please email admin@lionscamphorizon.orgI agree to the Consent Form. By e-signing below, I agree to the terms in the Lions Camp Horizon Consent Form (as outlined above). This includes Consent to Participate, Consent to Transport and Consent to Discharge. (In addition, a copy of the consent form will be emailed to you for your records once the application is received).Signature Sign Here Leading up to camp you will receive camp updates and email communication if there are additional items needed from you. Camper packets will be sent out about a month before camp with final information, check-in/check-out times, packing lists and any outstanding items needed. Our office hours are Monday – Friday from 9 am – 3pm. Please feel free to call the office at 360- 371-0531 or contact us via email at admin@lionscamphorizon.org with any questions.Other InformationAlthough we can accommodate upwards of 55 campers per session, we are limited to the number of individuals we may accept per session by conditions including, but not limited to, the use of wheelchairs, two-person lifts and transfers, medical treatments, tube feedings and other specialized care. We will do our best to place your applicant in the preferred session, but please bear in mind admission and session placement depends on many factors. The staff and Board of Directors reserve the right to refuse or cancel enrollment of an individual if we don’t believe we can accommodate the needs of the camper, or, if they pose a risk to himself/herself or others. Please feel free to provide further information you feel will be helpful for making your camper’s experience stress-free. If this is your camper’s first time attending an overnight camp, we encourage you to schedule a tour of our campus and a meeting with one of our Admission Staff between now and May.Data Collection Consent I consent to my submitted data being collected and stored. View our Privacy Policy for more infoFirst NameLast Name Previous Submit