Access Camp Registration (September 4-7, 2026)
PLEASE NOTE THIS APPLICATION IS FOR CAMP ACCESS: Upper Teens and Adults with Special Needs.
If you wish to register for another camp please visit www.bluegrasschristiancamp.org.
Space is limited and Blue Grass Christian Camp reserves the right to limit the number of campers to insure camper safety. Registrations will be processed in the order they are received.
Camper Information
Please fill out this form completely.If the information requested is not applicable in a required field, simply place N/A in the blank. If, in the course of the admissions process, it is determined that information provided is not adequate for the necessary care of the camper, the camper may miss an opportunity to attend camp. A camper's opportunity to attend is based upon the information provided and availability of staff to meet care requirements.
Camper's Name
*
First Name
Last Name
Camper Sex
*
Waitlist
Camper capacities are based on gender due to dorm capacities and number of volunteers. As specific gender will sell out before the other gender. If there are no more spots available based on the camper's gender, please register on our waitlist. We will contact you as soon as a spot becomes available to see if your camper is still available to attend Camp Access. Please use this link to sign up for the waiting list: https://form.jotform.com/261115122563143
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Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1921
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Year
Camper Email
*
example@example.com
Camper Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Picture of Camper
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Choose a file
This is not required but is helpful if you have a digital picture readily available.
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Height
*
Weight
*
T-shirt Size
*
Small
Medium
Large
XL
2XL
3XL
4XL
Previous Camping Experience?
*
Yes
No
If yes, where?
Who is filling out this form?
*
Camper is filling out form for self
Parent/Guardian is filling out form
Social Worker
Agency Employee
Church Leader
Friend
Other
Phone Number of person filling out form
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email of person filling out form
*
example@example.com
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Primary Contact Information
Parent, Social Worker, Agency Representative, Self
The camper is the primary contact and information about camp can be sent to phone/email listed above:
*
Yes
No
Primary Contact:
*
First Name
Last Name
Relationship to camper:
*
Contact Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email
*
example@example.com
Alternative Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Email
example@example.com
Address (if different from camper)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Name (if applicable):
Is this person a legal guardian of camper
*
Yes
No
Name and contact information for legal guardian if camper is not independent and guardian is not listed as primary contact:
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Contact Person (while at the camp session)
This needs to be someone who will NOT be at camp with you. Someone we can contact to make sure you know everything you need to know about camp like packing lists, transportation, and schedule. This might be a parent, caregiver, social worker, church worker, or someone else who is very helpful to you.
Contact Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email
*
example@example.com
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Emergency Contact
Please provide at least one emergency contact person, in the event that we cannot reach the Primary Contact. This person must be someone who WILL NOT be at camp and is NOT the Primary Contact.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Alternative Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 Name
First Name
Last Name
Emergency Contact #2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Alternative Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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Medications
Please fill out the Medications section including both prescription and non-prescription medications. All medications and a list of those medications will be turned over to the staff at the time the Camper is registered. If the camper requires any additional treatments or devices that must be administered by a qualified staff person, this must be brought to the attention of camp staff. All medications (including non-prescritption) will be dispensed by the designated member of the staff. Also, to aid in the smooth transition of the Camper, we ask that all medications (up to and including the 8PM dosage) be dispensed before leaving the Camper in the care of Camp staff.
Please list ALL medications
*
Does the camper use tobacco products?
*
Yes
No
Disabilities and Special Needs
It is very important that essential information about specific needs, difficulties, and assistance that would be needed so that we can assure that the proper level of care is provided. This is the information that we will use in arranging specific provisions for the Camper. Registrations that do not provide information regarding disabilities will not be processed and notification will be made to the person responsible for registering camper.
Disabilities (list all):
*
Disability Involves:
Legs
Arms
Hands
Head
Breathing
Other
Mobility:
*
Independent
with Wheelchair
with Assistance
with Electric Wheelchair
with Walker
Other
It is the responsibility of the parent/guardian/caregiver to provide a wheelchair (and/or necessary augmentative devices) that is safe and in optimum operational condition. Be certain that wheels, brakes and seat belts are safe and fully operational.
*
I understand
Vision:
*
Normal
Vision Impaired
Glasses
Legally Blind
Contacts
Communication:
*
Verbal
Signs Impaired
Speech Difficulty
Gestures
Nonverbal
Other
Allergies:
*
Precautions / Special Instructions
Seizure Disorder
*
Yes
No
If yes, Type & Frequency
Date of last Seizure
-
Month
-
Day
Year
Date
Wears Helmet?
Yes
No
Special Care for Seizures:
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Personal Care Instructions
Personal Care
*
Please Select
Independent
Requires Assistance
Dependent
Level of Care required for bathing:
*
Toileting
*
Please Select
Uses urinal / toilet
Uses Bedpan
Catheterizes self
Must be Catheterized
Wears "Depends"
Prompts after toileting
Assistance after toileting
Nighttime
*
Please Select
Nighttime incontinence
Wears "Depends"
Gets up during the night
No Issues during night
Other Nighttime Considerations:
*
Mealtime
*
Please Select
Uses utensils
Uses fingers
Special Container
Requires Bib
Uses Straw
Dietary Restrictions:
*
Activities Camper should NOT engage in:
*
Discipline/Inappropriate Behavior Concerns
*
Likes / Dislikes
*
Special Interests
*
Does the camper have any relationship difficulties with any other known campers?
*
Yes
No
If so, who?
Has the camper ever been the victim of abuse?
*
Yes
No
If yes, please explain:
Has the camper ever been charged with abuse or related misconduct?
*
Yes
No
If yes, please explain:
Does the camper display physically or verbally aggressive behaviors?
*
Yes
No
If yes, please provide the nature, intensity and triggers of those behaviors and suggestions for how to prevent or deescalate the behaviors.
Does the camper have a requested buddy?
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Medical and Insurance Information
Primary Care Name:
*
First Name
Last Name
Primary Care Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company
*
Insurance Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Subscriber's Name:
*
Policy Number
*
Group Number
*
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Agreements
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Payment
Payment Preference
*
Pay Now Online
Send Payment by Check
Request Financial Support
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Access Camp (September 4-7, 2026)
$190.00
$
190.00
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