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Camper Name_______________________________ Session(s)
_______________________________________
Age at camp _________________________________ Entering Grade
__________________________________
Our goal is to give your child the best possible experience this
summer. The information you provide will only be shared
when necessary with specific staff members. The more information
you provide, the better we can create a positive
camp experience for your child. If you have any questions,
please contact Camp Director Andrea Gordon at 612-374-0321
or [email protected]. Please complete and return this form
by May 30th.
Has your child been to Camp TEKO before? _________ If yes, for
how many years?_____________Has your child been away from home in
the past? ____________
If yes, was homesickness a concern or issue? Explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Describe your childs personality (Friendly? Shy? Outgoing?)
__________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________
What makes your child happy and how is it expressed?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What makes your child upset? How does s/he deal with
conflict?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How many siblings does your child have?
________________________________________________________________
Will any be at TEKO this summer?
______________________________________________________________________
Parents are: _____ Married ______ Separated ______ Divorced
_____ Other:_______________________
With whom does your child reside?
_____________________________________________________________________
Additional Information:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Activities in which your child participates when not at
camp:
__________________________________________________________________________________________________
Skills your child would like to learn at camp:
__________________________________________________________________________________________________
What does your child like to do in his/her free time?
__________________________________________________________________________________________________
Our staff teach TEKO-style swimming lessons and provide
appropriate games and fun in the water for a variety of skill
levels.
Please provide the following information about your childs past
swimming experience:
Has your child ever been swimming in a lake? Yes No
Has your child ever taken swimming lessons? Yes No
If yes, where? What was the last level completed?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please check as many of the following that apply to your
child.
ADD/ADHD Allergies Anxiety
Aspergers Syndrome Asthma Autism/PDD
Cerebral Palsy Conduct/OD Disorder Depression
Developmental Delay Diabetes Down Syndrome
Emotional/Behavioral
Disorder Epilepsy/Seizures Hearing Impairment
Learning Disability Obsessive-Compulsive Disorder Physical
Disability
Speech/Language Disability Tourettes Syndrome Visual
Impairment
Other:
__________________________________________________________________________________________
Does your child receive support services in school or in other
settings (special education / resource support,
paraprofessional, one-on-one aide, private therapist, private
tutor)? Yes No
If yes, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Please describe your childs eating habits:
No Special Dietary Needs Vegetarian Lactose Intolerant (Camper
should bring his/her own supply of Lactaid) Food Allergies
Please list:
__________________________________________________________________________________
OtherPlease explain:
_______________________________________________________________________________
Does your child keep kosher? ____ Yes ____ No
Additional Comments:
________________________________________________________________________________
What time does your child normally go to sleep at night?
___________________________________________________
Has your child slept overnight outside of your home (friends
houses, slumber parties, etc.)?
____ Yes ____ No
Describe the experience:
_____________________________________________________________________________
Describe your childs sleeping habits (waking up during the
night, bedwetting, walking/talking while asleep):
_________________________________________________________________________________________________
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***PLEASE REFER TO THE TABLE BELOW WHEN FILLING IN BUS
STOPS!***
My camper will be picked up and dropped off at the same bus stop
daily. I would like my campers pick up anddrop off location to be:
_________________________. (Please choose from the bus locations
listed in the table
below).
My camper is enrolled in aftercare at Temple Israel, so s/he
will take the bus from ___________________ in themorning and ride
the bus back to Temple Israel in the afternoon. (Please choose from
the bus locations listed in
the table below).
My camper has a unique travel schedule and will be riding on
more than one bus throughout the week. I wouldlike Camp Director
Andrea Gordon to call me to arrange transportation.
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Temple Israel 2324 Emerson Avenue South, Minneapolis 8:20 a.m.
4:15 p.m.
Breck School 123 Ottawa Avenue, Golden Valley 8:35 a.m. 4:00
p.m.
Beth El Synagogue 5224 West 26th
Street, St. Louis Park 8:20 a.m. 4:15 p.m.
Groveland Elementary 17310 Minnetonka Blvd, Minnetonka 8:40 a.m.
3:50 p.m.
Burroughs Elementary 1601 West 50th
Street, Minneapolis 8:15 a.m. 4:15 p.m.
Creek Valley Elementary 6401 Gleason Road, Edina 8:30 a.m. 4:00
p.m.
Adath Jeshurun Synagogue 10500 Hillside Lane West, Minnetonka
8:35 a.m. 3:50 p.m.
Zachary Lane Elementary 4350 Zachary Lane North, Plymouth 8:20
a.m. 4:05 p.m.
Greenwood Elementary 18005Medina Road,Plymouth 8:35 a.m. 3:50
p.m.
Public Landing by Wayzata Marine Corner of Tonkawa and North
Shore Drive 8:55 a.m. 3:30 p.m.
