Camp Paivika - Reservation Questionnaire for Summer Camp 2025

Dear Campers, Family Members and Care Providers:

Thank you for your interest in reserving a spot at Camp Paivika for this summer 2025! As some of you are aware we have had to make changes to our program delivery 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 6 will be designated for campers that do not require a high level of care (personal care and/or nursing care).

Friends and Family sessions 1 through 3 are for campers who require a higher level of care (personal care and/or nursing care). Campers may attend camp during these three sessions with their own companion to provide for their care. These sessions are open to more than just the camper and their companion. We hope additional family members or friends will enjoy camp too. 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! It is important you click Submit at the end. This will add a date and time stamp to our survey. We use this to develop our registration and waiting list.

When we review your reservation (in the order received), we will be contacting you:

  • If we do not have any questions, we will send you a registration link via email to register in ACTIVE. You will have two (2) weeks after you are notified to complete the on-line registration and pay the required $150 deposit. If not completed in the two (2) week time frame your registration will not be guaranteed.
  • If you are a first-time camper or we have questions or need additional information, we will contact you by phone and email. Please respond in a timely manner, as your registration link cannot be sent until we speak.

We strive to provide the best and safest program we can, and this process allows us to ensure the right fit for you camper's needs.

We look forward to speaking with you soon!
The Camp Paivika Staff
1.Camper Name:(Required.)
2.Camper's Disability(Required.)
3.Gender(Required.)
4.Has camper attended Camp Paivika previously?(Required.)
5.Does camper require  1-to-1 care or supervision?(Required.)
6.How old will camper be this summer?(Required.)
7.Mobility(Required.)
Walks unaided
Camper needs assistance
Camper uses braces/canes/walker
Camper uses wheelchair
Walking
8.If camper needs assistance with mobility, please add what type of assistance is needed.
9.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
10.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
11.If camper needs support with lifting and transferring or use of a mechanical transfer, please add how much your camper weighs.
12.Medications and Supplements(Required.)
Does not take any medication and/or supplements per day.
Takes 1 to 5 medications and/or supplements per day.
Takes 6 to 10 medications and/or supplements per day.
Takes 11 to 15 medications and/or supplements per day.
Takes 16 to 20 medication and/or supplements per day.
Takes more than 21 medications and/or supplements per day.
Number of medications or supplements taken per day
13.Types of medications needed at camp per day(Required.)
14.Nursing Care(Required.)
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
15.Personal Hygiene care needs(Required.)
Independent
Independent with prompting
Requires some assistance
Requires total assistance
Hygiene (brushing teeth, washing face, combing hair)
Showering
Dressing
16.Toileting(Required.)
Independent
Independent with prompting
Requires some assistance
Requires total assistance
Using toilet
Catheter
Wears incontinence briefs
17.Nighttime needs(Required.)
Sleeps through the night
Gets up during the night and will require assistance
Needs to be turned during the night
Camper overnight support
18.If camper has nighttime needs, please elaborate on what a typical night with support would look like.
19.Meal time support(Required.)
Independent
Requires some assistance (ie: setting up food/drink, cutting food)
Requires total assistance
Eating
Drinking
20.Special Dietary needs(Required.)
Yes
No
Requires a special diet
Requires food to be pureed or finely chopped
Has food allergies
21.Other things to know about my camper(Required.)
Never
Occasionally
Often
Daily 
Has challenging behaviors
Has temper outbursts
Has disruptive or assaultive behaviors
Wanders away from groups
Unable to sleep through the night
Challenging mealtime behaviors like refuses to eat
22.Please pick your top three choices(Required.)
First Choice
Second Choice
Third Choice
Session 1: Adults - 18 or older - June 22 - 27 (Sun - Fri)
Session 2: Adults - 18 or older - June 30 - July 5 (Mon - Sat)
Session 3: Adults - 18 or older - July 8 - 13 (Tue - Sun)
Session 4: Transition Age - 16 to 21 - July 16 - 21 (Wed - Mon)
Session 5: Children - 9 to 17 years old - July 24 - 29 (Thrus - Tue)
Session 6 : Adults 18 or older - Aug 1 - 6 (Fri - Wed)
Friends & Family Session 1 - 3 nights - Aug 9-Aug 12 (Sat - Tue)
Friends & Family Session 2 - 3 nights - Aug 15-Aug 18 (Fri-Mon)
Friends & Family Session 3 - 3 nights - Aug 21 - 24 (Thurs - Sat)
23.Name of friends they want to be in the same session
Once this reservation is reviewed, you will be notified of registration status.

Status possibilities:
  • Invited to Registered = Camp will send a registration link via email to register in Active.
  • Appointment Required = Camp staff will set an appointment to obtain additional information.
24.Name of Contact to conduct for an intake with or for the campers.
25.Email address:(Required.)
26.Cell phone number:(Required.)
27.Can we text you at the cell phone number listed above?(Required.)
28.What is the best time of day to reach you?(Required.)
29.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.(Required.)
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