Kent Sussex Industries (KSI) - Kamp Lenape Camper Application

The mission of KSI is to create opportunities for individuals with disabilities
to learn and grow. Through training, education and supportive programs and services, we
enable individuals to accomplish their personal and work-related goals.

Kamp Lenape Camper Application

Dear Parent/Guardian,

Thank you for your interest in KSI Kamp Lenape! We are so excited that you are interested in sending your child(ren) to KSI Kamp Lenape.

This summer we will be having two separate Kamp sessions so that we can serve additional Campers. Each Kamp session will be limited to 25 Campers on a first-come, first-served basis.

Session 1: June 23, 2025-July 18, 2025

Session 2: July 21, 2025-August 15, 2025

This is what we will need from you before we can process your Camper’s enrollment. Please upload these documents with the online application, or email them to KampLenape@ksiinc.org

Completed Application
IEP and/or BIP (upload with application)
Health Packet (this includes most recent physical and immunization record, and information about any prescriptions your child is currently taking) (upload with application)
Any information about who will be paying for Kamp

Note: If any of the above documentation is missing or incomplete, the application will be put on hold and a spot will not be held!

Please reach out to Michelle Cain at KampLenape@ksiinc.org or 302-422-4014 x 3009 with any questions.

*Camper First Name

*Camper Last Name

Camper Nickname (If Any)

Which Camp Session do you prefer?

June 23-July 18

July 21-August 15

No Preference

*Address

*City

*State/Province

*Postal Code

*Camper Date of Birth

*Camper Age

*Camper Gender

Male

Female

Camper Race

Caucasian

African American

Hispanic/Latino

Asian/Pacific Islander

Interacial

Undisclosed

*Primary Caregiver First Name

*Primary Caregiver Last Name

*Primary Caregiver Preferred Phone Number

Primary Caregiver Secondary Phone Number

Primary Caregiver Email Address

How do you plan to pay for Kamp?

School District Funded

DDDS Respite

Division of Family Services

Private Insurance

Private Pay

I need a Campership

Camper Information

*Mobility

Walks

Walker

Wheelchair

Can Propel/Drive Self

Fall Risk

*Transfers

No Assistance Needed

Needs Assistance

*Assistive Devices

None

AFOs

Glasses

Hearing Aid

Helmet

Headphones

*Communication

No serious difficulties expressing thoughts or wants

Uses Sign Language

Uses a Communication Device

*Eating

No Assistance Needed

Needs Assistance

*Diet

Normal

Blended/Pureed

Chopped

Feeding Tube

Choking/Aspiration Risk

Gluten Free

Diabetic

Food Allergies

Religious Restrictions

List and food allergies

List any food restriction based on religious beliefs

*Bowel Control

No Assistance Needed

Incontinent

Needs Assistance

*Bladder Control

No Assistance Needed

Incontinent

Catheter

Urinal

Disposable Undergarments

Needs Assistance

*Dressing

No Assistance Needed

Assistance Needed

*Camper T-Shirt Size

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Camper Social Background

*School

*Grade

*School Phone Number

*Does your child have a State Case Worker

Yes

Case Worker's Full Name

Case Worker Phone Number

*Primary Physician Name

*Primary Physician Phone Number

*Dentist Name

*Dentist Phone Number

Does the Camper have any behavior or sensory challenges?

Yes

If you answered YES above, please describe in detail

When do behaviors occur?

Describe effective methods to redirect or prevent behaviors

Does the Camper have trantrums that will intensify into aggressive and destructive behavior?

Yes

If you answered YES above, describe de-escalation methods/techniques

*Does the Camper have a Behavior Intervention Plan (BIP)?

Yes

Upload BIP

*Does the Camper have an IEP at school?

Yes

Upload IEP

*Describe any fears the Camper may have (i.e. dogs, insects, noises, etc)

*Describe any activities the Camper dislikes (i.e. crafts, exercise, etc.)

*Is your Camper able to participate in the swimming program?

Yes

*Can the Camper Swim?

Swims Independently

Cannot Swim

Requires Life Vest

Requires Floaties

Cannot Submerge in Water

Parent/Caregiver Information

*Custodial Parent/Guardian First Name

*Custodial Parent/Guardian Last Name

*Custodial Parent/Guardian Primary Phone

*Relationship to Camper

*Custodial Parent/Guardian Alternate Phone

*Custodial Parent/Guardian Email

*Custodial Parent/Guardian #2 First Name

*Custodial Parent/Guardian #2 Last Name

*Custodial Parent/Guardian #2 Relationship to Camper

*Custodial Parent/Guardian #2 Primary Phone Number

Custodial Parent/Guardian #2 Alternate Phone Number

In case of illness or injury, the Kamp will attempt to contact the parents/guardians at all numbers available. If the parent/guardian is unable to be reached, the emergency contacts will be called in the order they are listed. If no emergency contact is reached, appropriate medical care will be provided, including contacting the Camper’s physician and transfer by ambulance (if necessary) to a medical facility for further care and evaluation. The Kamp will continue to call the parents/guardians until one is reached.

*Emergency Contact #1 Full Name

*Emergency Contact #1 Phone Number

*Emergency Contact #1 Relationship to Camper

*Emergency Contact #2 Full Name

*Emergency Contact #2 Phone Number

*Emergency Contact #2 Relationship to Camper

Waivers and Releases

*Approval, Waiver, and Activity Consent: This application has my approval. While KSI’s Kamp Lenape will take every precaution, it is agreed that KSI is not legally responsible for any accidents, incidents, or injuries that may occur during camp session, assumes no responsibility for applicant’s personal property, and is released from liability for any accident, incident, or injury, except that may be covered by Camper’s insurance. Applicant has my permission to engage in all camp activities, except noted by myself or physician.

Agree

*Medical Treatment: The undersigned hereby authorizes and grants permission to any licensed/certified medical professional designated by KSI’s Kamp Lenape to provide routine medical care and administer medications, or to perform any emergency procedures on the camper that would be jeopardized by any delay in providing such treatment or performing such procedures.

Agree

*I, the undersigned hereby authorize KSI’s Kamp Lenape, its employees, agents, and assigns to release any pictures or photography taken of the above-named Camper for publication purposes of conveying information concerning the named individual and/or KSI Kamp Lenape. The undersigned hereby agrees to also hold KSI Kamp Lenape harmless of liability should such pictures or photographs either accompanied or unaccompanied by printed material, appear in publications by whomsoever published, circulated, or distributed. I understand that these materials may be published on KSI’s Kamp Lenape’s network, websites, and social media.

Photo Consent is Granted

I do not grant Photo Consent

I attest that all information provided in this application, materials, medical examination summary, and any supplemental items attached, are true and correct to the best of my knowledge.

*Caregiver Signature (Type Name Below)

*Upload a Recent Photo of Camper

*Upload Most Recent Physical

*Upload Vaccination Records

Confirm

Cancel

Contact Info

301 N. Rehoboth Boulevard
Milford, DE 19963

5 Academy St
Georgetown, DE 19947

Phone: 302-422-4014
Fax: 302-422-5848

Monday - Friday
8:00am - 4:00pm

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