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Wild Horse Creek Camp 2992 CR 2285 Telephone, Texas 75488 Camp Office: 903-664-2485, or Cell Phone: 469-235-4573 or 469-450-7960
Participant Application, Authorization & Release
Name __________________________________ Gender: Male Female (Last) (First) (MI)
Age: _____ Height: _______ ' _______" Weight: _________ lbs DOB: ___/___/_______
Street Address: ________________________________________________________________ City: ___________________________________________ State: ______ Zip: _______________
Home Phone: (____) ____-______ Work Phone (_____) ____-______ Cell Phone: (___) ____ - ______ Email: _________________________________________________________________
Employer/School: ______________________________________________________________________ Street Address:__________________________________________________________ City: _________________________ State: __________ Zip: _____________________ Home Phone: (____) ____-______ Work Phone (_____) ____-______ Cell Phone: (___) ____ - ______ Email: _________________________________________________________________
Parent/Legal Guardian: _______________________________________ Mother Father Guardian Street Address: _______________________________________________________________ City: _________________________________________ State: ______ Zip: ________________
Home Phone: (____) ____-______ Work Phone (_____) ____-______ Cell Phone: (___) ____ - ______ Email: _________________________________________________________________
MEDICATION: (include prescriptions, over-the-counter, name, dose and frequency) ________________________________________________________________________________________________________________________________________________________________________________________
PHYSICAL FUNCTION: (i.e. Mobility skills such as transfers, walking, wheelchair use, driving/bus riding)
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PSYCHO/SOCIAL FUNCTION: (i.e. Work/school, including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.)
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GOALS: (i.e. why are you applying for participation? What would you like to accomplish?)
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SPECIAL NEEDS/LIKES/DISLIKES:
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