Dallas R.O.C.K. | DFW Celiac Support Group









Packet Forms
	Welcome Packet (includes all forms)
Individual Forms
	Welcome Letter
	Consent Form
	Packing List
	Medical Release
	Medical Exam
	Medicine Form
	Dismissal Form

If you prefer to speak to someone about the Great Gluten Escape Camp, use the Contact page. Important for 2010: A camp deposit of $100 or full payment must be received within 7 days after registration or your registration will be removed from the system.You will receive an email before your registration is removed. Click here to pay the deposit amount of $100. After receipt of your registration and payment all camp correspondence will done via email. Parents/Campers are responsible for notifying the camp registrar via email if there is a change of email address. It is our policy to return all registrations that are not complete, that do not have the complete deposit, or that have contingencies. For more information please contact the camp registrar via email or 972-727-4654. Late Registration/Partial Payments: Effective on May 1, 2010 the camp fee will increase to $425 and full payment will be required at the time of registration. Any paid camp deposit will be applied to the late registration fee. If written cancellation notice is received by May 15, 2010, any camp fees paid will be refunded (not including the non-refundable deposit of $100). Additionally, any remaining balances not paid in full before May 1, 2010 will be subject to a late fee of $30. To make a partial payment click here

Registration Date:	(Ex.MM/DD/YYYY)
Camper Information
Last Name:
First Name:
Middle Name:
Preferred Name:
Address:
City:
State:	(Please choose state)
Zip Code:
Phone:	(Ex. 999-999-9999)
Age:
Gender:	Male Female
Date of Birth:	(Ex.MM/DD/YYYY)
School Grade (use current year):
Payment Method: Payment may be sent to: Great Gluten Escape Camp 1019 Rockefeller Lane Allen TX 75002	Check or Credit Card - Credit card payments may now be completed using Paypal! You will be redirected at the end of this registration process. Prospective Camper - select this option if you are not ready to formally register. The Camp Director will contact you to help answer any questions.
Dietary Restrictions: DF Note: The camp will serve gluten-free food and accommodate dairy free diets as needed. All dairy free campers will be required to stay dairy free during camp. No other food restrictions will be accommodated by the camp.	Diagnosed with Celiac Disease * Diagnosed with Gluten Intolerance * Dairy Free - see note about Dairy Free *Leave this box un-checked if the camper is not diagnosed (by a licensed physician) with celiac disease/gluten intolerance. This information is collected specifically for grant writing purposes. The camper does not have to be a diagnosed celiac to attend camp.
T-shirt Size:	Youth Small (6-8) Youth Medium (10-12) Youth Large (14-16) Adult Small Adult Medium Adult Large Adult XL
Ethnicity (optional)	Black Hispanic Asian/Pacific Islander Native American White
Camper is under the custodial care of:	Both Parents Mother Only Father Only Other (Specify)
Mother or Guardian Information
Name:
Address:
City:
State & ZIP:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Father or Other Guardian Information
Name:
Address:
City:
State & ZIP:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Camp Referral
How did you hear about our camp?
Camper Health History
Check all that apply:	Animal Allergy Food Allergy Insect Bites/Stings Allergy Soy Allergy Plants/Pollen Allergy Peanut Allergy Tree Nut Allergy Medicine Allergy Other Allergies (Use Comments for additional details)
Is an EpiPen required?
Chronic/Recurring Conditions
Check all that apply:	Asthma Kidney Disease Heart Disease Diabetes Ear Infection Seizures Emotional Disturbances Sickle Cell Epilepsy Blood Disorder Hypertension Constipation Hearing Impairment Musculoskeletal Disorder
Other Conditions?
Allowable Medicines
Check all that apply:	Acetaminophen Ibuprophen Benadryl Calamine Insect Repellent Sunscreen AntisepticOintment Claritin
Other Information
Check all that apply:	Contact Lenses Eye Glasses Dental Appliance
Other Special Devices?

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