Adventure Rehab Camp Participant Application

Welcome and thank you for applying to our Adventure Rehab Camp! We are intentionally building each group so that we can provide a rich and rewarding experience for every person who applies. These camps are best suited for individuals with Parkinson's, multiple sclerosis, stroke, brain injury and spinal cord injury. This application is non-binding, however it indicates your desire to be placed in an upcoming session. You will be contacted individually by our staff after submitting the application.
Contact us with questions: connect@destinationrehab.org, 541-241-6837

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* 1. Full Name

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* 2. Phone number

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* 3. Email

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* 4. How do you prefer to be contacted? (select all that apply)

phone

mailing address

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* 5. Age

under 18

18-64

65+

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* 6. Where will you be traveling from? (US city/state or other country)

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* 7. Please rate your reasons for wanting to attend our Adventure Rehab Camp

	Not important	Somewhat important	Very important	Extremely important
Improve my level of independence	Improve my level of independence Not important	Improve my level of independence Somewhat important	Improve my level of independence Very important	Improve my level of independence Extremely important
Improve my strength and/or flexibility	Improve my strength and/or flexibility Not important	Improve my strength and/or flexibility Somewhat important	Improve my strength and/or flexibility Very important	Improve my strength and/or flexibility Extremely important
Try out some new sporting activities	Try out some new sporting activities Not important	Try out some new sporting activities Somewhat important	Try out some new sporting activities Very important	Try out some new sporting activities Extremely important
Experience new activities and outings	Experience new activities and outings Not important	Experience new activities and outings Somewhat important	Experience new activities and outings Very important	Experience new activities and outings Extremely important
Challenge myself to push to a new level of ability	Challenge myself to push to a new level of ability Not important	Challenge myself to push to a new level of ability Somewhat important	Challenge myself to push to a new level of ability Very important	Challenge myself to push to a new level of ability Extremely important
Connect with peers in a similar situation	Connect with peers in a similar situation Not important	Connect with peers in a similar situation Somewhat important	Connect with peers in a similar situation Very important	Connect with peers in a similar situation Extremely important
Enjoy a luxury vacation in a mountain town	Enjoy a luxury vacation in a mountain town Not important	Enjoy a luxury vacation in a mountain town Somewhat important	Enjoy a luxury vacation in a mountain town Very important	Enjoy a luxury vacation in a mountain town Extremely important
Increase my ability and confidence with getting out and about	Increase my ability and confidence with getting out and about Not important	Increase my ability and confidence with getting out and about Somewhat important	Increase my ability and confidence with getting out and about Very important	Increase my ability and confidence with getting out and about Extremely important

Other (please specify)

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* 8. All of our activities include accessible and adaptive options, however we are unable to provide nursing support for tasks such as: dressing, medication, toileting, showering, etc. Please indicate that you understand and are able to be independent with these tasks, or that you will be bringing a member of your own support team to the camp.

I am fully independent in dressing, bathing, medication, eating, showering, etc (adaptive equipment is allowed).

I require assistance with one or more of these items and will be bringing a member of my support team to assist me.

I require assistance and am unable to bring someone. Please contact me about options.

I am fully independent but would like to bring a support team member to experience the camp with me. (family, friend or caregiver)

Other (please specify)

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* 9. Please give some details about your condition, including amount of assistance needed (or equipment), and any specific accommodations, questions or concerns you might have about the rehab camp. Other comments welcome here too.