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Dempsey Center›Registration Forms›Space to Breathe Camper Info

Space to Breathe Camper Info

Camper Name:(Required)
MM slash DD slash YYYY
Emergency Contact #1:(Required)
Emergency Contact #2
Does your child have any diagnosed medical or mental health conditions?(Required)
Does your child have any food allergies, sensitivities, or dietary restrictions?(Required)
List any food allergies, sensitivities, or dietary restrictions:
Food:
Details:
 
Does your child have any allergies (medication or environmental)?(Required)
List any medical or environmental allergies:
Allergy:
Details:
 
Does your camper have any medications (prescription or over the counter) they are currently taking?
List the name, dosage and administration instructions:
Medication Name:
Dosage:
Administration Instructions:
 
Please be prepared to send all medications to camp in their original prescription containers with camper’s name and dosing instructions and/or labelled in original over the counter containers. This includes any epi pens, inhalers, or other PRN medications.
Does your child need any special accommodations to be successful at camp?(Required)
Is there anything else it is important for us to know about your child or your family situation currently?(Required)
Camper’s T-Shirt Size (adult sizes):(Required)

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Find Us

Lewiston
29 Lowell Street
Lewiston, ME 04240

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 8:00 AM - 7:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: 8:00 AM - 4:00 PM (Virtual)
Sat-Sun: Closed

South Portland
778 Main St.
South Portland, ME 04106

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 8:00 AM - 7:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: 8:00 AM - 4:00 PM (Virtual only)
Sat-Sun: Closed

Find Us

Lewiston
29 Lowell Street
Lewiston, ME 04240

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 8:00 AM - 7:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: 8:00 AM - 4:00 PM (Virtual)
Sat-Sun: Closed

South Portland
778 Main St.
South Portland, ME 04106

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 8:00 AM - 7:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: 8:00 AM - 4:00 PM (Virtual only)
Sat-Sun: Closed

Donations

Donations may be mailed to:
Dempsey Center
PO Box 277
Auburn, ME 04212


Checks should be made out to the Dempsey Center, please do not mail cash.
EIN Number: 82-1547129

Donations

Donations may be mailed to:
Dempsey Center
PO Box 277
Auburn, ME 04212


Checks should be made out to the Dempsey Center, please do not mail cash.
EIN Number: 82-1547129

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