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Connect Camp
for Adults with
Dementia
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Camp Enrollment
respite for families, fun for loved ones
Name & Nickname
Date
Referred By
D.O.B.
Place of birth
Spouse Name
Children's Name
Place of residence
Are they alive or deceased?
Spouse is alive
Spouse is dead
Dead or Alive?
Dementia diagnosis? If any, which type?
When was the diagnosis?
Select what applies
Ambulatory
Walks with personal assistance
Walks with walker or cane
Uses wheelchair
Can they engage in conversational give and take?
Yes
No
Somewhat
Are they used to a show of affection?
Yes
No
Formal education level and work background?
Military background?
Any allergies?
Religious affiliation?
Any history of behavioral issues?
Any stressors/triggers that would agitate them?
Medical issues, surgeries, or replacements?
Any interests/ hobbies?
Caregiver Portion
First name & Last name
Email
Address
Phone
Relationship to camper
Best contact method
Phone call
Phone message
Email
Date
I understand this is a donation-based ministry run by volunteers ($10 per program). Pictures and videos may be taken and used to document the program and promote community awareness. Camp members must be promptly picked up at the end of the program. We reserve the right to limit program access to any camp member.
Must be available by phone all times during the program
Submit
Thanks for registering. See you there!
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