Camp Wonder Recommendation Form

Child's Name:

Age

Birthdate

Gender

Parent/Guardian

Address

Address

State

City

Zip

Phone (Home)

Phone (Other)

Email Address:

Physician's Name

Address

Address

State

City

Zip

Phone (Office)

Phone (Emergency)

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 child.

Able to perform daily skin care regimen without assistance.

Requires some assistance to perform daily skin care regimen.

Requires extensive assistance to perform daily skin care regimen.

Estimate time required for daily bandaging:

Additional Condsiderations:

Other medical considerations: (i.e., asthma, severe allergies, behavioral problems, attention deficit disorder, etc.)

Behavioral problems: Yes   No

Requires Wheelchair: Yes   No