Dear Friends of Silver Towers Camp,

Enclosed is the application packet for the 2008 summer session. Please review each document, complete and
return with the non-refundable application fee. We encourage you to return the application packet as soon as
possible to ensure the best opportunity for your camper to attend the sessions of his or her choice. Campers will
be assigned based on age and ability levels and your preference selection. Campers may attend any of the sessions
that reflect their age category. Special permission to attend a different session is possible by asking the director.
Preference will be given to VT residents.

All applications must be received no later than June 1, 2008

Check list of items to be mailed with completed application:

1. Completed Camper Application:

2. Medical Form: must be completed and signed by approved licensed medical personnel.
3. Application fee: $25.00 check/money order to Silver Towers Charities, Inc. required for each session.

Please call me:

Incomplete application packets will not be accepted. Each packet must include items 1-3.

Mail completed packet with application fee to:

Earl Cavanagh
1116 US Route 5
East Dummerston, VT 05346

You will be notified of your acceptance and the session(s) you will attend

Camp Fees
A non-refundable deposit of $25.00 for each session is required for all campers. Mail this deposit with your
application form. This deposit must be paid separately for each camper.

The cost of tuition for each week is $300.00 for all campers. The deposit may be deducted from
the cost of tuition. The deposit must be paid before you receive notification of the camper’s acceptance
and his or her session assignment.
2008 Silver Towers Camp Application
Name Date of Birth Age Sex M F
Social Security # Phone # ( )
Home Address City St. Zip
Mailing Address City St. Zip

Names of persons to be contacted in case of emergency

Home Provider or Care Giver Phone # ( )
Address City St. Zip

Parents or Legal Guardian Phone # ( )

Address City St. Zip

Health Insurance Coverage

Is the camper covered by family medical/ hospital insurance? Yes No
Medicare # Medicaid #
► Photocopy of front and back of health insurance card must be attached to this form

This section must be completed by the parent/guardian for camper’s attendance.

Permission to Provide necessary Treatment or Emergency Care: I hereby give permission for medical personnel selected to order and approve various
medical/treatment: to release any records necessary for insurance purposes; to provide/arrange necessary transportation for me/or camper in the event I
cannot be reached in an emergency. I hereby give permission to the medical personnel to secure and administer treatment, including hospitalization for the
person named above. I agree to abide by the restrictions as specified above during camp.

Signature of parent/guardian or adult camper

Printed Name Date

Silver Towers will have eight one-week sessions. Each session will have approximately 60 campers, 30 males and 30 females. Each
weekly session will be designed to meet the age, social and functional level of the campers. Two week stays or longer are available for
those wishing to stay up to three weeks.

Please indicate which session(s) you would prefer, with #1 being your first choice. Every effort will be made to place the camper in the
session(s) requested whenever possible, however this cannot be guaranteed. Preference will be given Vermont residents.

Camp Fees are $300.00 per session for all campers. A $25.00 application fee must accompany each application.

2008 Camp Schedule

Session 1 June 22 to June 28 Session 5 July 20 to July 26
(ages 6-22) (ages 23-70)

Session 2 June 29 to July 5 Session 6 July 27 to Aug 2

(ages 6-22) (ages 23-70)

Session 3 July 6 to July 12 Session 7 Aug 3 to Aug 9

(ages 23 - 70) (ages 23-70)
Session 4 July 13 to July 19 Session 8 Aug. 10 to Aug 16
(ages 23-70) (ages 23-70)
Page 1
Camper Health Information

Please describe any current health issues:

List any Allergies:

Heart or Blood Pressure Problems:

Respiratory Problems:

Diabetes:

Skin Problems:

Special Diet:

Seizure Disorder Yes No

Controlled: Yes No
Type: Grand Mal Petit Mal Psychomotor
Frequency:

Does camper usually run a normal temperature? Yes No

Is camper sensitive to sun? Yes No

Is camper sensitive to bug bites Yes No

Please list past significant medical histories:

Please list all medications and treatments (Dosage and times of administration):

Page 2
What best describes camper’s vision?
Wears Glasses Normal Vision Has Functional Vision
Is Legally Blind Blind

How does camper communicate with others? Uses Speech Understands Speech
Uses Sign Language Understands Sign Uses Adaptive Communication Device

What is the best way to communicate with camper?

Behavioral Challenges:
Indicate those that best describe camper:
Aggression toward people Tantrums Self Injury Hyperactive
Aggression toward objects Manipulative Swears Poor Peer Relations

Inappropriate Sexual Behavior Withdrawn Non-Compliance

Other Challenges not listed:

What is the most effective way to deal with camper’s behavioral challenges?

Does camper have specific behavioral procedures followed at home, school or day care program?
Yes No

If yes, please describe:

Describe campers Daily Living Skills:

Independent Needs Help Needs Total Care
Dressing:
Bathing:
Hygiene:
Toileting:
Eating:
Bed-Making:
Clothing Care:

Does camper wet bed? Yes No

If yes, how often?

Page 3
Please use this space to provide any further information that will help us better serve your
camper:

Does camper have problems taking medicine? Yes No

Best method to administer medicine:

Camper’s Physical Challenges

Cerebral Palsy Spina Bifida Muscular Dystrophy Quadriplegic

Paraplegia Ambulatory Uses Wheelchair Uses Crutches
Walks with
assistance

Camper’s Mental Challenges

Developmentally Delayed Mild Moderate Severe

Autism Mild Moderate Severe
Emotionally Behaviorally Disturbed
Down Syndrome

Please List any other:

History of physical, mental, or sexual abuse:

Other:

Camper’s Hearing
Has Normal Hearing Has Functional Hearing
Is Hard of Hearing Is Deaf
Page 4