CAMO PROGRAM APPLICATION

We require that you complete the information below with accurate and detailed responses in order to be considered. All applications are received by the CAMO Program Director and are strictly confidential.

APPLICANT INFORMATION

Last Name *

First Name *

Email *

Birth Date *

// (mm/dd/yyyy)

Phone (xxx-xxx-xxxx) *

Mailing Address *

City *

State *

Zip *

Closest MAJOR airport you prefer (we do not fly out of regional airports due to the cost) *

If necessary, are you willing to pay for your airfare to/from Denver International Airport? *

Yes
No

Gender *

Height (ex: 5' 11" or 5-11) *

Weight in lbs. *

Emergency Contact Name *

Emergency Contact Relationship *

Spouse
Partner
Son
Daughter
Mother
Father
Caregiver
Other

Emergency Contact Phone (xxx-xxx-xxxx) *

Branch (Be prepared to email a copy of your DD214) *

Army
Navy
Air Force
Marines

Status *

Active
Retired
Reserves

Are you able to provide a copy of your form DD214?

Yes
No

Summer Retreat Applying For:

Archery I, July 10 - 15, 2019
Archery II, August 14 - 19, 2019
BLESMA (this is a closed retreat), September 3 - 9, 2019
Mark Christine Memorial Fly Fishing, September 11 - 16, 2019

Winter Retreat Applying For:

Sarah Williams Volf Women's Mountain Retreat, December 1 - 6, 2019
Couples Retreat I, December 14 - 19, 2019
Couples Retreat II, January 6 - 11, 2020
Couples Retreat III, January 13 - 18, 2020
Cheyenne VA Retreat, January 19 - 24, 2020
Fort Campbell VA Retreat, February 3 - 8, 2020
Couples Retreat IV, February 10 - 15, 2020
Couples Retreat V, February 16 - 21, 2020
BLESMA, February 24 - 29, 2020
Learn to Ski/Snowboard/Snowbike I, March 16 - 21, 2020
Learn to Ski/Snowboard/Snowbike II, March 23 - 28, 2020
Learn to Ski/Snowboard/Snowbike III, April 1 -6, 2020

If applying for a winter retreat, what is your preferred sport:

Skiing
Snowboarding

If applying for a winter retreat, what is your ski/snowboard level of experience?

Never-ever (never used ski/snowboard equipment)
Beginner (can make turns on easy slopes)
Intermediate (can make turns on medium difficulty terrain)
Advanced (confident on upper level difficulty terrain)
Expert

Are you barred from receiving VA benefits based on service? *

Are you barred from receiving VA pension or compensation based on character of discharge? *

IF YOU ARE TRAVELING WITH A SPOUSE OR CAREGIVER YOU MUST FILL OUT THE FOLLOWING QUESTIONS:

Spouse/partner/caregiver preferred sport:

Skiing
Snowboarding

Spouse/partner/caregiver level of experience?

Never-ever
Beginner
Intermediate
Advanced
Expert

Spouse/Partner/Caregiver - Full Name (as it appears on legal documents)

Spouse/Partner/ Caregiver - Date of Birth

Spouse/Partner/Caregiver - Height (ex: 5' 11" or 5-11)

Spouse/Partner/Caregiver - Weight in lbs.

PARTICIPANT DISABILITY INFORMATION

What is your VA Disability Rating? *

Describe your disability: *

Disability onset date and cause of disability: *

Have you had a seizure in the last 2 years? *

Yes
No

Are you able to walk? *

Yes
No

If not, what mobility device do you use?

If you use a manual wheelchair, are you able to transfer to a vehicle passenger seat?

Yes
No

Please list all special equipment you will bring with you (ie: electric wheelchair, walker, C-PAP, etc):

Please give us a brief description of your disability including specific needs and requirements. Please list primary and secondary disabilities. This information will help set us, and you, up for success. *

Please list all medications, include dosages and dosage time *

Do you have a shunt? *

Yes
No

Please list all allergies *

List the names/dates of all adaptive military programs you have attended in the last 2 years (including CAMO):

Please provide a biography of who you are and why you think a CAMO retreat would be helpful in your life. This can include, but is not limited to, your goals, hobbies, family, injury, etc. *

Do you have a service dog? *

Yes
No

If yes, will your service dog attend with you? *

Yes
No

You agree you are applying to participate in outdoor recreational and non-medically supervised programming. Participation includes activities that can be hazardous and involve risk of physical injury and/or death. You attest your current medical condition allows participation in these activities: *

Yes
No

You have consulted your primary care physician or disability specialist regarding your physical and/or mental condition to attend: *

Yes
No

You attest your primary care physician and/or disability specialist has given you permission to attend a physically and mentally challenging program that takes place for 6 days at 8,000 feet above sea level: *

Yes
No

You attest you have provided Challenge Aspen with ALL medical and disability information thereby allowing Challenge Aspen to make informed and safe decisions regarding your possible participation: *

Yes
No

By selecting "Yes" below, and hitting the Submit button, I understand and agree that I will not be considered to attend a program if the information I have provied above is not complete, honest, and accurate. *

Yes

**PLEASE NOTE: If you are applying for a Couples Retreat, both partners attending will need to fill out the Participant Intake Form (PIF) and the DSUSA waiver, which you will receive in an email. They can also be found on our website.

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CAMO PROGRAM APPLICATION