2024 PPW Family Summer Camp application form

2024 Pediatric Pain Warrior Family Summer Camp APPLICATION

The Pediatric Pain Warrior, a program of the U.S. Pain Foundation, is thrilled to announce its 3rd Annual Pediatric Pain Warrior Family Summer Camp will be held June 23-27, 2024, at Morgan’s Camp in San Antonio, TX. This five-day summer camp is for our pediatric pain warriors and their families. Camp is open to pediatric pain warriors under age 18 and their immediate family and caregivers. Attending siblings can be older than 18."

During the week, families will participate in a variety of fun camp activities, including equine therapy, ropes courses, swimming, and more! There will also be educational sessions and daily support groups. Plus, there may be a few surprises from our favorite mascot, Pete the Penguin!

Applications must be in by March 20. All accepted campers will be notified of their application status by the end of March. Please direct all questions to Casey Cashman, Director of the Pediatric Pain Warrior Program, at casey@uspainfoundation.org.

1. Contact Information *This question is required.

First Name of person completing application

Last Name of person completing application

Street Address

City

State

Zip

Country

Email Address

Phone Number

3. Do you have more than one pediatric pain warrior attending camp? *This question is required.

Name and Age of Pediatric Pain Warrior *This question is required.

First Name

Last Name

Age

What specific conditions/diseases does your pediatric pain warrior live with? Please review this list carefully and select all that apply. Please note: conditions are listed in alphabetical order. *This question is required.

Name and Age of first pediatric pain warrior.

First Name

Last Name

Age

What specific conditions/diseases does your first pediatric pain warrior live with? Please review this list carefully and select all that apply. Please note: conditions are listed in alphabetical order. *This question is required.

Name and Age of second pediatric pain warrior.

First Name

Last Name

Age

What specific conditions/diseases does your second pediatric pain warrior live with? Please review this list carefully and select all that apply. Please note: conditions are listed in alphabetical order. *This question is required.

Name and age of third pediatric pain warrior. *This question is required.

First Name

Last Name

Age

What specific conditions/diseases does your third pediatric pain warrior live with? Please review this list carefully and select all that apply. Please note: conditions are listed in alphabetical order. *This question is required.

Name and age of fourth pediatric pain warrior. *This question is required.

First Name

Last Name

Age

What specific conditions/diseases does your fourth pediatric pain warrior live with? Please review this list carefully and select all that apply. Please note: conditions are listed in alphabetical order. *This question is required.

Name and age of fifth pediatric pain warrior. *This question is required.

First Name

Last Name

Age

What specific conditions/diseases does your fifth pediatric pain warrior live with? Please review this list carefully and select all that apply. Please note: conditions are listed in alphabetical order. *This question is required.

Name and age of sixth pediatric pain warrior. *This question is required.

First Name

Last Name

Age

What specific conditions/diseases does your sixth pediatric pain warrior live with? Please review this list carefully and select all that apply. Please note: conditions are listed in alphabetical order. *This question is required.

4. How many other children will be attending camp? What are their ages? (If no other children will be attending, please put N/A.) *This question is required.

5. For all other individuals attending camp, please review this list carefully and select if any other attendees live with the following conditions. Select all that apply. Please note: conditions are listed in alphabetical order. *This question is required.

6. Has your family ever attended a Pediatric Pain Warrior Family Summer Camp? *This question is required.

7. Has your family attended any of other Pediatric Pain Warrior events or programming (either in-person or virtually), such as family retreats, community days, educational webinars, etc.? *This question is required.

8. How did you hear about the Pediatric Pain Warrior Family Summer Camp? (Select all that apply.) *This question is required.

The Pediatric Pain Warrior Facebook page
U.S. Pain Foundation social media
U.S. Pain Foundation newsletter
U.S. Pain Foundation website
Health care provider
Friend
Word of mouth
Another organization
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

From which organization did you hear about the Pediatric Pain Warrior Family Summer Camp? *This question is required.

9. Why does your family want to attend the summer camp? *This question is required.

10. What do you hope your family gets out of attending summer camp? *This question is required.

11. Safe and Respectful Environment acknowledgement.
At the Pediatric Pain Warrior Family Summer Camp, bullying is inexcusable, and we have a firm policy against all types of bullying. Our Camp philosophy is based on our commitment to a safe and respectful environment which ensures that every camper has the opportunity to feel supported, gain self-confidence, and acquire knowledge and tools to empower them throughout their lives. *This question is required.

12. Accommodations Acknowledgement
Morgan’s Camp provides cabins for parents, campers, and their siblings. There are two types of cabins, depicted on the camp website: the “Bexar” cabin accommodates 32 people in two rooms with eight (8) bunk beds each and a common area adjoining the rooms; the “Alamo” cabin accommodates 16 people in one room with eight (8) bunk beds together with one (1) small private room accommodating up to three (3) people.

The sleeping rooms in both cabin types have adjacent bathrooms containing three (3) shower stalls and three (3) toilet stalls. Each cabin is also air conditioned and equipped with a refrigerator, washer and dryer. Requests for a private cabin will be determined on a case-by-case basis. *This question is required.

13.

Adult Camper/Participant Registry Check:
All campers/participants 18 years and older, and counselors under the age of 18, will be checked through the Free National Sex Offender Registry website (https://www.nsopw.gov/) within one week of the start of the Event Term.

*This question is required.

14. Health, Safety and Covid-19 acknowledgement:
Please know that the camp will adhere to all health, safety, and Covid-19 guidelines and protocols enacted by the Centers for Disease Control and Protection (CDC), in addition to such guidelines and protocols provided by Morgan’s Camp and U.S. Pain prior to and during the Camp. All accepted campers must agree to abide by these protocols. *This question is required.

15.

Release and Waiver of Liability:
I understand that there are inherent dangers and risks associated with participating in the Camp. In consideration of my family being accepted to participate in the Camp, I understand that my family is coming to Camp voluntarily. If at any point my family does not feel comfortable participating in an activity, I understand that it is my responsibility to discontinue participation.

*This question is required.

16. Would you like to be added to U.S. Pain Foundation's pediatric pain mailing list? *This question is required.

17. Any final information you would like to share with us at this time.