Basic Information Name of group/individual/family *:
Agency:
Contact Name *:

Contact Address Street: City: State: Zip:
Work Phone: Cell Phone: Email *:

Camper Information Estimated number of campers with disabilities *:
Estimated number of staff/caregivers *:
Estimated number of family members *:
Will there be a working dog with this group?:
Expected date and time of arrival at the camp *:
Expected date and time of departure from the camp *:
Are you staying over night at the camp?:
If yes, dates you will be staying overnight at the camp:

Driver and Primary Contact Information

Person driving vehicle to the camp:
Cell phone of driver or other contact person coming to the camp *:
Email address of primary person with campers:
Cell phone of primary person with campers: