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 Andrea@templeisrael.com. 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:
__________________________________________________________________________________________________
__________________________________________________________________________________________________

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:
__________________________________________________________________________________________________
__________________________________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

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: __________________________________________________________________________________

Other
Please 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):
_________________________________________________________________________________________________

***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 and
drop 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 the
morning 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 would
like Camp Director Andrea Gordon to call me to arrange transportation.

------------------------------------------------------------------------------------------------

Temple Israel
Breck School
Beth El Synagogue
Groveland Elementary
Burroughs Elementary
Creek Valley Elementary
Adath Jeshurun Synagogue
Zachary Lane Elementary
Greenwood Elementary
Public Landing by Wayzata Marine

2324 Emerson Avenue South, Minneapolis

123 Ottawa Avenue, Golden Valley
5224 West 26th Street, St. Louis Park
17310 Minnetonka Blvd, Minnetonka
1601 West 50th Street, Minneapolis
6401 Gleason Road, Edina
10500 Hillside Lane West, Minnetonka
4350 Zachary Lane North, Plymouth
18005 Medina Road, Plymouth
Corner of Tonkawa and North Shore Drive

8:20 a.m.
8:35 a.m.
8:20 a.m.
8:40 a.m.
8:15 a.m.
8:30 a.m.
8:35 a.m.
8:20 a.m.
8:35 a.m.
8:55 a.m.

4:15 p.m.
4:00 p.m.
4:15 p.m.
3:50 p.m.
4:15 p.m.
4:00 p.m.
3:50 p.m.
4:05 p.m.
3:50 p.m.
3:30 p.m.