Save the date for Camp Rehab: May 27th-29th, 7:30 AM - 3:30 PM!

Accepted applicants will receive an email from camprehab@wtrc.com at a later date with more information.

Camper Information

Campers Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Gender

Male
Female

Campers Age

Campers Date of Birth

Shirt Size

Swimming - My child has permission to get into a swimming pool under supervision and with a life preserver

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

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

Emergency Contact Phone Number

Campers respective with

Alternate Phone Number

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.

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.

Signature

Clear Signature

Abilene Camp Rehab Registration

Save the date for Camp Rehab: May 27th-29th, 7:30 AM - 3:30 PM!

Camper Information

Guardian Information

Consent Forms