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2026 Abilene Rehab Camp Sign Up
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hereby camp Center
Camper Information
Campers Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Gender
*
Male
Female
Campers Age
*
5
6
7
8
9
10
11
12
Campers Date of Birth
*
Shirt Size
*
Youth XSmall
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Swimming - My child has permission to get into a swimming pool under supervision and with a life preserver
*
Yes
No
Campers Diagnosis
*
If unsure, add what they work on in therapy.
Campers Physician
*
Does the Child need any Medication? If so please list medication dosage and time taken below. (Medication will be given to the nurse each morning of camp with instructions, and should be picked up from nurse each day at the end of camp)
*
Allergies (food, plants, medications, etc.)
Special Needs or Precautions
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Guardian Information
By adding this information you are consenting to receive email and sms notifications related to Camp Rehab updates. Ex Schedule, Weather Alerts, Emergency notifications.
Parent or Guardian Name
*
First
Last
Phone
*
Email
*
Emergency Contact Name
*
First
Last
Relationship
*
Mother / Father
Grandparent
Aunt / Uncle
Sibling
Babysitter/Nanny
Other
Emergency Contact Phone Number
*
Alternate Phone Number
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Consent Forms
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by West Texas Rehab Center during the selected camp. In exchange for the acceptance of said child’s candidacy by West Texas Rehab Center . I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless West Texas Rehab Center and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against West Texas Rehab Center . including all affiliates, all participants and, if applicable, owners and lessors of premises used to conduct the event.
*
Yes
No
If the answer is no, the camper will not be accepted.
I hereby grant to West Texas Rehabilitation Center, their agents, successors, assignees, and affiliates, and their respective employees, officers, directors, board members, and representatives (collectively “Producers”) the right and permission to film, photograph, and record me, transcribe the recording, and to use my name, voice, image, information about me and any ideas or materials that I provide Producers (collectively, the “Materials”) in works created by Producers (the “Program”) and in connection with advertising, publicizing, broadcasting, producing, and exploiting the Program, in any and all media and mediums now known hereafter developed, in perpetuity. I understand that Producers are under no obligation to incorporate my appearance in the Program. Producer may edit and Video as it sees fit, and may resnlate the Material into languages other than English.
*
Yes
No
Signature
*
Clear Signature
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