Heart Camp Registration | University Health

Camper Information

Camper's first name: *

Camper's middle name:

Camper's last name: *

Camper's birth date: *

Camper's biological gender: *

Camper's pronouns:

Camper's preferred name:

Camper's address: *

Camper's city: *

Camper's state: *

Camper's zip code: *

Camper's primary language:

Is translation assistance needed?

Yes

Camper's race/ ethnicity:

Additional Information About Camper

Has the camper attended an overnight camp before? *

Yes

Has the camper attended a Camp Discovery before? *

Yes

Camper's T-shirt size: *

Child S

Child M

Child L

Adult S

Adult M

Adult L

Camper's second choice of T-shirt size: *

Child S

Child M

Child L

Adult S

Adult M

Adult L

In case the first choice is not available.

Has the camper adjusted to the diagnosis and treatment of heart defect? *

Yes

Is the camper participating in normal activities based on camper's age? *

Yes

Ex. school activities, spending time with friends and enjoying other activities, etc.

What the camper's hobbies/interests?

Ex. what do camper enjoys.

How does the camper interact with others?

Ex. shy, outgoing, friendly, etc.

What is the most important thing you want the camper to experience at camp? *

If selected other, please provide details about challenges:

Please add any additional information that camp staff may need to know about.

Any special needs, fears or anxieties the camper has that the staff should know about? *

Yes

If yes, please add details below

Are there any specific activities that may require special accommodation for the camper during camp? *

Yes

If yes, please add details below

Does the camper have any dietary restrictions and/or special food needs? *

Yes

If yes, please add details below

Describe any special or unusual bedtime or sleep habits the camper has. *

Ex. sleepwalking, nightmares, awakening, bedwetting, snoring.

Is camper functionality at current age level? *

Yes

Please describe camper's funtionality.

Does camper needs assistance getting dressed? *

Yes

Does camper needs assistance showering? *

Yes

Does camper needs assistance going to the bathroom? *

Yes

Does camper needs assistance walking to place to place? *

Yes

Does camper needs assistance eating? *

Yes

Add details if daily activity not listed or any of the above selected.

Does the camper depend on any special equipment? *

Yes

Ex. crutches, wheelchair, prosthesis, feeding pump, nebulizer, etc.

Please describe below

If yes, please be sure to provide these items with your child at camp.

Does the camper has any vision or hearing problems? *

Yes

If yes, please provide details below

Do you (parent/guardian) give permission to the camper to swim? *

Yes

Does the camper know how to swim? *

Yes

If the camper needs full time help while in the water, describe help needed.

Do you (parent/guardian) give permission to the camper to ride horseback? *

Does the camper know how to ride horseback? *

Yes

If camper needs full time help to ride horseback, describe help needed.

Has the camper ever had discipline problems? *

Yes

These include outside the home or been physically aggressive with others?

If yes, please provide details below.

Has the camper ever been arrested, summoned to court, or charged with delinquent conduct? *

Yes

If you answered yes, you will be contacted by Kids Heart Camp leadership for more information about the specific situation. It is important to answer truthfully.

Medical Status Information

Camper's cardiac diagnosis: *

Is the camper currently on treatment? *

Yes

Please select camper's treatment center. *

CHofSA (Santa Rosa)

Methodist Children’s Hospital

University Health Children’s Hospital

SAMMC

Other

If "other" selected, please type name of center.

Does camper have any special devices? *

Yes

If selected yes, please select special device.

Oxygen

PICC Line

Ventilator

Pacemaker

Ostomy

G-tube

NG tube

If selected pacemaker, please add make and model.

Is camper currently being treated for any other medical condition? *

Yes

Ex asthma, ADD, diabetes, etc.

If yes, please describe medical condition below.

Is camper allergic to any medications? *

Yes

Is the camper allergic to any foods, environmental triggers, latex, or other substance? *

Yes

If selected yes, please provide details below.

Any other medical needs the camper has that medical staff should know about?

Yes

If selected yes, please explain below.

Has camper had their first period?

Yes

Only females campers are required to answer this question

Has camper had chicken pox? *

Yes

Has camper had a splenectomy? *

Yes

Is the camper up-to-date on their immunizations? *

Yes

**All immunizations must be up to date and a copy of immunization record included with application**

Parent/Guardian Information

Parent or guardian full name: *

Parent or guardian address: *

Parent or guardian city: *

Parent or guardian state: *

Parent or guardian email address: *

Parent or guardian cell phone: *

Parent or guardian work phone: *

Second Parent/Guardian Information

Second parent/guardian full name: *

Second parent/guardian home address:

Second parent/guardian city:

Second Parent/Guardian State:

Second parent/guardian home phone Number:

Second parent/guardian cell phone number: *

Second parent/guardian work phone Number:

Emergency Contact Information

The emergency contact should be someone other than parent/guardian. Parents/guardians will be contacted first, followed by the emergency contact.

Emergency contact full name: *

Emergency contact preferred language:

Emergency contact cell phone: *

Emergency contact home phone:

Emergency contact relationship to camper: *

Cardiologist Information

Cardiologist's name *

Cardiologist's institution: *

e.g. UT Health San Antonio, University Medicine Associates, etc.

Cardiologist's phone: *

Pediatrician Information

Pediatrician's name: *

Pediatrician's institution: *

Pediatrician's phone number: *

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2024 Heart Camp Registration

Camper Information

Additional Information About Camper

Medical Status Information

Parent/Guardian Information

Second Parent/Guardian Information

Emergency Contact Information

Cardiologist Information

Pediatrician Information