Camp Courage 2024 —Application Form
This form is to be completed by a parent or guardian and submitted by April 19, 2024. ( Deadline has been extended through May 10th)This form must be completed in its entirety. 

Camp Courage
July 14- 19, 2024
Host Camp: Camp Horizons
Sponsored by: Epilepsy Foundation of CT
386 Main Street ● Middletown, Connecticut 06457
860.346.1924 ● www.epilepsyct.com
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CAMPER INFORMATION
Camper’s Name
Nickname
Address
City
State
Zip Code
Phone Number
Sex
Clear selection
Age
Date of Birth
MM
/
DD
/
YYYY
T- Shirt Size (Adult Sizes)                                                  (Not guaranteed after June 1, 2024)
Clear selection
SCHOOL INFORMATION
School Name
School Phone Number
Grade in School (fall)
MEDICAL INFORMATION
Type of Seizure (s)
Medications
Other Medical Conditions
Emotional/Behavioral Problems (please explain)
Does your child have a behavior plan at school? If yes, please explain.
Cognitive Impairments (please explain)
Physical Impairments (please explain)
Vagus Nerve Stimulator
Clear selection
If yes,  date of implantation
MM
/
DD
/
YYYY
If yes, can the camper use magnet on self?
Special Dietary needs (i.e. Ketogenic diet, Gluten free, Modified Atkins etc.)? Please Explain.
Neurologist or Physician Name
Neurologist or Physician Phone Number
One-on-one personal assistant needed for all daily activities? If yes, please explain.
PARENT/GUARDIAN INFORMATION
Mother’s/Guardian Name
Mother’s/Guardian Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
Email
Father’s/Guardian Name
Father’s/Guardian Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
Email
I heard about this camp from:
How many times have you attended this camp?__
Please write a brief statement stating why you would like your child to attend this summer camp.
I do hereby authorize any school or medical personnel having record or confidential information pertaining to the above applicant to disclose such information to the Epilepsy Foundation of Connecticut, Inc.
Parent or Guardian Signature (Please type your name below in lieu of signature)
Date
MM
/
DD
/
YYYY
$25 non-refundable application fee
Payment must be postmarked by April 14th.

Please make your check payable to: Epilepsy Foundation of Connecticut

Please send payment to:
Epilepsy Foundation of Connecticut, Inc.
386 Main Street
Middletown, CT
06457-3360

Application fees can also be paid online by going to epilepsyct.com and clicking on the “Donate” button.  Just specify your donation is a Camp Courage application fee.
Fast Facts
The Application Process:

Children and teens ages 8-25 years at the time of camp with a primary diagnosis of epilepsy and on anticonvulsant medication, receiving other treatment for seizures or are under follow up care are eligible to apply.

Campers will be considered for admission by the Camp Advisory   Committee after completion of application and receipt of application fee. Prior attendance does not guarantee acceptance.

Location: Camp Courage is now being hosted at beautiful Horizons located in South Windham CT. Campers and counselors bunk together in comfortable, air controlled cabins. Campers attend three programs in the morning and four in the afternoon. Evening activities are opportunities for the entire camp to come together for entertainment such as campfires, dances, movies, field games and music.  


Camp Counselors: Counselors are employed by Camp Horizons and receive specialized training in seizure recognition and first aid.  Camper to counselor ratio is typically 1:5.  A licensed nurse will be in residence at all times.

 

 The Cost to You: $300 per camper (does not include application fee)
(Cost to EFCT:  $1999.00 per Camper)
Any scholarship money received should be sent to the Epilepsy Foundation of Connecticut NOT Camp Horizons
 
A $25 non-refundable application fee is due postmarked by April 19, 2024 to:
Epilepsy Foundation of Connecticut
386 Main Street Middletown CT 06457

Application fees can also be paid online by going to epilepsyct.com and clicking on the “Donate” button.  Just specify your donation is a Camp Courage application fee.
Camp Horizons Open House

Join us on April 6th at 1:30 PM for a group tour of camp with the Camp Director and a member of Epilepsy Foundation staff. Please be prompt in your arrival. 

You will have a chance to see the campgrounds, meet the camp director and staff from the EFCT. You will have an opportunity to have all your questions answered before you decide to send your child to camp.

Location:
Camp Horizons
127 Babcock Hill Rd, South Windham, CT 06266

Please call Monica @ 860.346.1924 or email monica@epilepsyct.com by April 3, 2023 to confirm your attendance.

 

Our Sponsors
We are grateful to both current and past sponsors of camp courage.  Their generosity allows us to offer you a camping experience at an affordable cost.

* Bob's Discount Furniture Foundation

* Winokur Foundation

* Davenport Hatch Foundation

* Tinty Foundation, Inc.

* The Dempsey Family

* Shawn Lefevre

*Siefert Associates- Bridge to Cure

 

 

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