Camp Questionnaire

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Service Dog Camp Questionnaire

* Indicates required field

Name of Service Dog Recipient: *

Do You Need Accommodations For Medical Equipment? *

Name of Care Giver Attending Camp With You: *

If Yes (Medical Equipment), Please Explain: *

Name Of Anyone Else Attending Camp With You: *

Preferred Email Address: *

Do You Have Allergies? *

Yes No

If Yes (Allergies); Please List: *

Do We Need To Take Special Precautions When Doing Outdoor Activities? *

Yes No

If Yes (Outdoor Activities); Please Explain: *

If You Have Additional Medical Needs We Should Be Aware Of, Please Explain: *

Do You Have Sensitivity To Heat/Cold? *

Yes No

If Yes (Sensitivity); Please Explain: *

Do You Have Any Food Allergies? *

Yes No

We will try to accommodate food preferences where we can, however, many of our meals are provided by volunteer families, and we may not be able to include, or not include, certain foods.

What Beverages Do You Drink? *

Water Diet Soda Regular Soda Juice Coffee Tea

Please List Any Beverage Flavor Preferences: *

List Three of Your Favorite Fruits: *

Any Fruits You Cannot or Will Not Eat? *

Please List Three of Your Favorite Vegetables: *

Any Vegetables You Cannot/Will Not Eat? *

Are You A Picky Eater? *

Are You On A Medical Diet? *

If Other (Diet), Please List: *

What Types of Snacks Do You Prefer? *

Fruit Chips Nuts Granola Bars Vegetables Cookies Other

If Other; Please List: *

Select Your Favorite Types of Foods: *

American Mexican Italian Chinese Indian

Has There Been Any Changes In Your Household Since We Had Our Skype Visit? *

Examples: Added a new pet in the home; Grandma moved in the basement; Medical Issues Changed, Etc?

What Size T-Shirt Do You Wear? *

What Size Shirt Does Your Primary Care Giver Wear? *

Is There Anything Else We Should Know About You (Or About Your Caregiver)? *

If Applicable, What Size Shirt Does Your Secondary Care Giver Wear? *

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