Submit your Camp Wonder Recommendation form online! Please complete the following information and we will process your order immediately. (*required field)
       
 

Child & Parent/Guardian Information

 
  Child's Name*  
  Birthdate  
  Age   Gender   
  Address*  
  City*  
  State Zip  
  Home Phone*  
  Other Phone  
  Email Address*  
       
       
 

Physician's Information

 
  Physician's Name*  
  Address*  
  City*  
  State Zip  
  Office Phone*  
  Emergency Phone  
       
       
 

Medical Condition

 
  Skin Condition  
  Severity of Condition  
  Extent of Condition  
  If limited, what areas
are affected? 		 
 
Level of Care Required: In order to accurately assess the amount of medical care required, please indicate the level of daily care required by this children. 		 
 
Able to perform daily skin care regimen without assistance. 		 
  Requires some assistance to perform daily skin care regiment  
  Requires extensive assistance to perform daily skin car  
  Estimated time required for daily bandaging:    
 
Additional Considerations: 		 
 
Behavioral Problems:   Yes No 		 
  Requires Wheelchair:   Yes No  
     
  Children must meet the age criteria at time of camp: 7-16 years old.
Campers will be selected without regard to sex, race, national origin, or religion.