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Dear Campers, Family Members and Care Providers:

Thank you for your interest in reserving a spot at Camp Paivika for this summer 2024!  We are making changes to our program this summer to ensure that we are able to provide a safe and meaningful experience for all of our campers.  The first step is for us to be able to evaluate the care and supervision needs for each camper and work together with you to identify the correct session placement.   Sessions 1 through 5 will be designated for campers that do not require a high level of care (personal care and/or nursing care).  Sessions 6 through 7 will be reserved for Friends and Family sessions for campers who require a higher level of care (personal care and/or nursing care).  Campers may attend camp during these two sessions with their own companion to provide for their care.  We will explain more when we speak with you after you complete this questionnaire. 

Please complete ALL required fields on this questionnaire.

We will be reviewing and completing registrations in the order these reservation questionnaires are COMPLETED so don't delay!
When we review your reservation (in the order received), we will be contacting you:

  - If we have no questions, we will set up your registration in ACTIVE and you will have two (2) weeks after you are notified to            complete the on-line registration and pay the required $150 deposit.

  - If we have questions or need additional information, we will contact you by phone.  Please respond in a timely manner, as your      registration cannot be completed until we speak. 

Thank you for your understanding and patience as we implement this new system.  We look forward to speaking with you soon!
The Camp Paivika Staff

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1. Camper Name:

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2. Camper's Disability

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3. Has camper attended Camp Paivika previously?

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4. Does camper require  1-to-1 care or supervision?

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5. How old will camper be this summer?

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6. Mobility  - answer only if camper DOES NOT use a wheelchair

  Walks unaided Camper needs assistance Camper uses braces/canes/walker
Walking

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7. Mobility and Wheelchair Use - answer only if camper DOES use a wheelchair.

  Yes No
Uses manual wheelchair while at camp
Uses electric wheelchair while at camp
Needs wheelchair for long distances
Needs wheelchair sometimes, less than 25% of the day
Needs wheelchair all of the time

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8. Mobility - Transfers - answer only if camper DOES use a wheelchair

  Yes No
Camper self-transfers
Camper can bear weight during transfers
Camper uses a Hoyer lift for transfers

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9. If camper needs support with lifting and transferring or use of a mechanical transfer, please add how much they weigh.

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10. Medications and Supplements

  Does not take any medication or supplements. Takes 1 to 5 medications or supplements. Takes 6 or more medications or supplements.
Number of medications or supplements taken per day

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11. Types of medications needed at camp per day

  Yes No
Eye drops
Pills, capsules, chewables, gummies
Liquids
Nose drops
Inhaler
Topicals 
Injections

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12. Nursing Care

  No Yes - 5 to 15 minutes Yes - 16 to 29 minutes Yes - 30 minutes +
Catheter
Bowel Care
G-Tube
Trach Care
Wound Care
Breathing Treatment
Diabetic Care

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13. Personal Hygiene care needs

  Independent Independent with prompting Requires some assistance Requires total assistance
Hygiene (brushing teeth, washing face, combing hair)
Showering
Dressing

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14. Toileting

  Independent Independent with prompting Requires some assistance Requires total assistance
Using toilet
Catheter
Wears incontinence briefs

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15. Nighttime needs

  Sleeps through the night Gets up during the night and will require assistance Needs to be turned during the night
Camper overnight support

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16. Meal time support

  Independent Requires some assistance (ie: setting up food/drink, cutting food) Requires total assistance
Eating
Drinking

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17. Special Dietary needs

  Yes No
Requires a special diet
Requires food to be pureed or finely chopped
Has food allergies

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18. Other things to know about my camper

  Never Occasionally Often Daily 
Has challenging behaviors
Has temper outbursts
Has disruptive or assaultive behaviors
Wanders away from groups

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19. Please pick your top three choices

  First Choice Second Choice Third Choice
Session 1: Transition Age (age 16-25) - June 24-June 29 (Mon-Sat)
Session 2: Children (age 9-17) - July 2-July 7 (Tue-Sun)
Session 3: Adults (age 18+) - July 10-July 15 (Wed-Mon)
Session 4: Adults (age 18+) - July 18-July 23 (Thur-Tue)
Session 5: Adults (age 18+) - July 26 – July 31 (Fri-Wed)
Friends & Family Session 1 - 5 nights - Aug 9-Aug 14 (Fri-Wed)
Friends & Family Session 1 - 3 nights - Aug 9-Aug 11 (Fri-Sun)
Friends & Family Session 2 - 5 nights - Aug 16-Aug 21 (Fri-Wed)
Friends & Family Session 2 - 3 nights - Aug 9-Aug 18 (Fri-Sun)

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20. Email address:

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21. Cell phone number:

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22. Can we text you at the cell phone number listed above?

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23. What is the best time of day to reach you?

Once this reservation is reviewed, you will be notified of registration status. 

Status possibilities:
  • Registered = Camp staff registered you/your camper in Active
  • Appointment Required = Camp staff has reached out to you to set an appointment for a phone/Zoom call to go over questions/additional information

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24. Once notified that you/your camper is registered, you will have 2 weeks to complete the online registration forms (not including the medical form) and pay a minimum of the $150 deposit.

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