August 7 – 10, 2025 • Payson, Arizona

Name: Camp Brain Application & Payment
Start: 2025-08-07T00:00:00-07:00
End: 2025-08-10T23:59:59-07:00
Location: Whispering Hope Ranch

Camp Brain Application & Payment

Welcome to the 2025 Camp Brain Application form

The camp will take place August 7 – 10, 2025 in Payson, Arizona.

Before beginning this application, we want you to know about a few important requirements.

All campers must read and agree to the Camper Code of Conduct. This will be sent to you a month before camp. Failure to follow any of the rules could result in a camper being asked to leave early at their own expense.
Due to high fire risk in the Camp location, there is a ZERO TOLERANCE smoking AND vaping policy while participating in Camp.
Activities of Daily Living (ADLs) such as bathing, toileting, getting dressed, eating, among other examples.
All Campers must EITHER:
— Be able to independently manage their own ADLs, OR
— Bring a care giver or support person to assist with all of their ADLs
Campers attending Camp Brain are required to have medical insurance coverage.

Agenda: The final agenda and packing list for camp will be sent after you complete your application and payment. Camp activities that we are planning for you include comedy night, campfire, talent show, Mongolian Rim viewing field trip, and kayaking with Arizona Adaptive Watersports.

Cost: Camp Brain registration fee includes food, lodging, and all activities. The cost is $350 per camper and is due by July 31, 2025. Campers must be able to complete their activities of daily living on their own or they are welcome to bring one caregiver. The cost for the caregiver is $200.

Guests: Adult guests can join us starting at 9:30 AM on Sunday for breakfast and pack up. Per our host facility’s policy, absolutely no children under 10 years of age are allowed on the camp grounds.

Scholarships: A limited number of scholarships to attend camp are available. The first round of scholarship applications is due June 1st. Additional scholarships will be made available as donations allow. Reach out to our Helpline at 888-500-9165 or email info@biaaz.org.

Transportation: A limited number for transportation spots are available from Ability 360 to camp for $100 round-trip. Transportation is not secured until you apply for and receive notice that there is room.

2025 Camper Full Application

"*" indicates required fields

Step 1 of 4 - Introduction & Verification

Welcome to the 2025 Camp Brain Application form. The camp will take place August 7 – 10, 2025 in Payson, Arizona.

Before beginning this application, we want you to know about a few important requirements.

All campers must read and agree to the Camper Code of Conduct. Failure to follow any of the rules could result in a camper being asked to leave early at their own expense.
Due to high fire risk in the Camp location, there is a ZERO TOLERANCE smoking AND vaping policy while participating in Camp.
Activities of Daily Living (ADLs) such as bathing, toileting, getting dressed, eating, among other examples.
1. All Campers must EITHER:
  1. Be able to independently manage their own ADLs, OR
  2. Bring a care giver or support person to assist with all of their ADLs
Campers attending Camp Brain are required to have medical insurance coverage.

After your camp application is accepted, campers must fill out the Whispering Hope electronic waiver before attending camp.

Guests: Adult guests can join us starting at 8:30 AM on Sunday for breakfast and pack up. Per our host facility's policy, absolutely no children under 10 years of age are allowed on the camp grounds.

Scholarships: A limited number of scholarships to attend camp are available. The first round of scholarship applications is due June 1st. Additional scholarships will be made available. Reach out to our Helpline at 888-500-9165 or email info@biaaz.org.

Transportation: Limited transportation is available from Ability 360 to camp for $100 round-trip. Transportation is not secured until you apply for and receive notice that there is room.

Verification*

I agree to reading and following the rules in the Code of Conduct

I agree to not smoke or vape at any time during the Camp

I agree to manage my own ADLs OR Bring a support person to assist with managing my ADLs

Application

Who is completing this application?*

Survivor of brain injury attending camp

Someone Else

Name Of Person Filling Out Application*

Email of Person Filling out Application*

A copy of this completed application will be sent to this address

Relationship Of Person Filling Out Application*

I am the legal guardian of the survivor applying for camp*

Yes, and I can provide guardianship documentation, if needed

Camp Participation*

Please check the dates you would like to attend

THURSDAY-August 7

FRIDAY - August 8

SATURDAY-August 9

SUNDAY-August 10

WEBINAR: Preparing for Camp Brain*

Join us as we talk about the basics of preparing for Camp Brain! You can join one or more of these LIVE sessions. The information will repeat. We’ll review the agenda, accommodations, menu, activities, and more.

You will receive a separate email confirmation with information on how to join this webinar.

SATURDAY - 6/14 | 1:00 - 2:00 pm

THURSDAY 6/19 | 6:30 - 7:30 PM

Camper Name*

First Last Nick Name

Birthdate*

Month

Day

Year

Preferred Phone

Cell

Home Landline

Other

Cell Phone*

Home Landline Phone*

Other Phone*

Email*

A copy of this completed application will be sent to this address

Contact Preference*

Home Landline

Cell Phone

Other Phone

E-mail

Text Message

T-SHIRT Size*

Small

Medium

Large

XX-Large

XXX-Large

XXXX-Large

Address*

Street Address City State Zip Code

DEMOGRAPHICS

Gender*

Select from List

Ethnicity*

Select from List

Acquired Brain Injury (ABI) Diagnosis

Number of Brain Injuries*

Cause of Most Recent Brain Injury*

Lack of Oxygen

Assault

Trauma/Shaken Baby Syndrome

Assault

Blast Injuries/Explosion

Fall

Gunshot

Medical Interventions (Such as surgery)

Medical/Disease (COVID-19, Tumor, MS)

Motor Vehicle Crash

Motorized Recreational (Boats, ATV, etc)

Non-Motorized Recreation (Bicycle, Skateboard, Inline Skates, Horseback Riding)

Stroke

Struck By/Against an Object

Toxic Effects (Chemicals, Radiation)

Mechanism Unknown

Cause of Most Recent Brain Injury - Anoxic*

Near Drowning

Opioid Overdose

Strangulation

Other

Cause of Most Recent Brain Injury - Assault*

Domestic Violence

Abusive Head Trauma/Shaken Baby Syndrome

Other

Cause of Most Recent Brain Injury - MedicalDisease*

Abscess

COVID-19

Epilepsy/Seizure

Hydrocephalus

Meningitis

Multiple Sclerosis

Tumor

Other

Cause of Most Recent Brain Injury - Medical intervention*

Electroconvulsive Therapy Treatment

Surgical

Other

Cause of Most Recent Brain Injury - Motorized Recreational*

ATV

Golf Cart

Motorized Boat

Other

Cause of Most Recent Brain Injury - Motor Vehicle Crash*

Car Crash

Moped

Motorcycle

Other

Cause of Most Recent Brain Injury - Non-Motorized Recreation*

Bike

Horseback

Skateboard

Watercraft

Other

Cause of Most Recent Brain Injury - Stroke*

CVA

Hemorrhagic

Ischemic

TIA

Cause of Most Recent Brain Injury - Struck By/Against*

Pedestrian

Other

Cause of Most Recent Brain Injury - Toxic Effects*

Alcohol

Chemical Exposure

Chemotherapy

Radiation for medical treatment

Street Drugs

Other

Date of Most Recent Injury*

If you do not know the exact date, please round to the nearest date that you do know. For example, if you know the injury was in August of 2013, enter 8/1/2013. If you know if was in 1995, enter 1/1/1995.

Month

Day

Year

Additional ABI Diagnosis Information - Most Recent injury

Cause of First Brain Injury*

Lack of Oxygen

Assault

Trauma/Shaken Baby Syndrome

Assault

Blast Injuries/Explosion

Fall

Gunshot

Medical Interventions (Such as surgery)

Medical/Disease (COVID-19, Tumor, MS)

Motor Vehicle Crash

Motorized Recreational (Boats, ATV, etc)

Non-Motorized Recreation (Bicycle, Skateboard, Inline Skates, Horseback Riding)

Stroke

Struck By/Against an Object

Toxic Effects (Chemicals, Radiation)

Mechanism Unknown

Cause of First Brain Injury - Anoxic*

Near Drowning

Opioid Overdose

Strangulation

Other

Cause of First Brain Injury - Assault*

Domestic Violence

Abusive Head Trauma/Shaken Baby Syndrome

Other

Cause of First Brain Injury - MedicalDisease*

Abscess

COVID-19

Epilepsy/Seizure

Hydrocephalus

Meningitis

Multiple Sclerosis

Tumor

Other

Cause of First Brain Injury - Medical intervention*

Electroconvulsive Therapy Treatment

Surgical

Other

Cause of First Brain Injury - Motorized Recreational*

ATV

Golf Cart

Motorized Boat

Other

Cause of First Brain Injury - Motor Vehicle Crash*

Car Crash

Moped

Motorcycle

Other

Cause of First Brain Injury - Non-Motorized Recreation*

Bike

Horseback

Skateboard

Watercraft

Other

Cause of First Brain Injury - Stroke*

CVA

Hemorrhagic

Ischemic

TIA

Cause of First Brain Injury - Struck By/Against*

Pedestrian

Other

Cause of First Brain Injury - Toxic Effects*

Alcohol

Chemical Exposure

Chemotherapy

Radiation for medical treatment

Street Drugs

Other

Date of First Injury*

Month

Day

Year

Additional ABI Diagnosis Information - First injury

Additional Non-ABI Diagnosis

(Spinal Cord Injury, Behavioral Health, Developmental Disability, etc.)

Transportation

Availability Notice*

At this time there are a limited number of transportation spots available. Should additional spots become available, would you like to be notified?

YES

Will you be driving your own vehicle?*

YES

Is someone else driving you to Camp Brain?*

YES

Driver Name*

First Last

Phone*

VEHICLE INFO

If “YES”, please provide the following:

Vehicle Make*

Model*

Year*

How many seats in the vehicle?*

Driver License*

Car License (include state)*

This field is hidden when viewing the form

SECTION END

NOTE: Please plan to arrive on Thursday between 4-6PM and leave between 11AM-1PM on Sunday.

SPECIAL NEEDS

(NOTE: You are required to provide / bring your own equipment)

Mobility*

The camp has hills; assistive devices are recommended to be brought to camp. Please indicate what type of mobility aids you use:

N/A

Electric Wheelchair

Manual Wheelchair

Scooter

Crutches

Walker

Smartdrive

Firefly

Do you use special equipment?*

(e.g. lift, shower chair/seat, etc.)

YES

If "YES" please specify below:*

Hoyer Lift

Rolling Shower Chair

Shower Seat

Tub Bench

OTHER

If "OTHER" please specify below:

Do you require a CPAP machine or other medical equipment while you sleep that requires access to a power outlet?*

YES

EMERGENCY CONTACTS

Please select someone who is not accompanying you on this trip. Note that we will also contact this person if we are unable to contact you about last-minute information related to your trip. If you become injured or violate the rules of the camp, this person will be available to pick you up at Whispering Hope Ranch.

PRIMARY CONTACT

Primary Contact Name*

First Last

Phone*

Email*

An email notifying your emergency contact of their role for you will be automatically emailed to them.

Relationship*

SECONDARY CONTACT

Secondary Contact Name*

First Last

Phone*

Email*

An email notifying your emergency contact of their role for you will be automatically emailed to them.

Relationship*

Additional Attendee

Each camper may bring a caregiver to assist them with their activities of daily living for the cost of $200.

Will you be bringing anyone to camp with you?*

YES

Who will you be bringing?*

Professional Caregiver

Other Caregiver

Agency*

Relationship*

Additional Attendee Information

Name*

First Last

Phone*

Email*

A copy of this completed application will be sent to this address

T-Shirt Size*

Additional Attendee Emergency Contact

Name*

First Last

Phone*

Relationship*

Please list any allergies your Additional Attendee has or enter “NONE”*

Please list any medical conditions your Additional Attendee has or enter “NONE”*

Health Care Needs

Do you require assistance to complete your daily personal care needs?

(bathing, bowel care, feeding, grooming, dressing, toileting, transfers, etc.)

YES

Camp Brain staff and volunteers will not be available to assist with daily personal care such as toileting. Campers requiring this assistance will need to have a Additional Attendee with them. Volunteers will be on site to assist with activities and provide for the general overall safety of camp.

Will your Additional Attendee be providing all your assistance needs?*

YES

SERVICE DOGS ONLY

Will you be bringing a trained service animal with you?

YES

Are you currently in a doctor's care for any health problems?*

YES

Are you prone to seizures?*

YES

Seizure Type*

What causes your seizures?*

Typical seizure duration:*

Seizure Recovery Protocol*

When was your last seizure?*

Month

Day

Year

Do you have allergies to any medications?*

YES

If "YES" please LIST the MEDICATIONS and the REACTIONS below*

Are you allergic to latex or latex products?*

YES

Are you allergic to any foods, animals, or insects?*

YES

Please describe which foods, animals, or insects you are allergic to below:*

FOOD PREFERENCES

Do you need a special diet?*

YES

Special Diet Details*

Select all that apply

NO Dairy

NO Nuts

Gluten Free

Vegetarian

Vegan

OTHER

Other Special Diets*

This field is hidden when viewing the form

Additional Attendee Food Needs

Does your Additional Attendee need a special diet?*

YES

Additional Attendee Special Diet Details*

NO Dairy

NO Nuts

Gluten Free

Vegetarian

Vegan

OTHER

Additional Attendee Other Special Diets*

This field is hidden when viewing the form

End Section

Additional Information

Any comments or additional information you'd like to provide?

MEDICAL INSURER

INSURER*

Phone*

Group Number*

ID Number*

Whispering Hope Ranch | Brain Injury Alliance of Arizona

PHOTOGRAPHY RELEASE

PHOTOGRAPHY RELEASE*

I consent to and authorize the use and reproduction by Whispering Hope Ranch (“WHR”) or Brain Injury Association of Arizona of any and all photographs and any other audio-and/or video recordings of the voices and images taken of me and/or my child(ren)/ward(s) for promotional material, educational activities, use on WHR’s website, exhibitions or for any other use for the benefit of WHR. I hereby waive any claim for payment or other compensation for any such use by WHR of my and/or my child’s(children's)/ward’s photographs and/or any other audio and/or video recordings.

I HAVE CAREFULLY READ THE ABOVE RELEASE AND CONSENT WITH FULL KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE.

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Name

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Tickets

The numbers below include tickets for this event already in your cart. Clicking "Get Tickets" will allow you to edit any existing attendee information as well as change ticket quantities.

Camper Registration

$350.00

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Caregiver Registration

$200.00

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Total: $0.00