Paddy Rossbach Youth Camp Application

Thank you for your interest in youth camp! If you are aged 10 to 17 and living with limb difference or limb loss in the United States, we invite you to complete the following application for the Paddy Rossbach Youth Camp. All travel and camp expenses are covered through the generous support of our donors.

Camp:  June 11-16, 2018
Deadline:  March 2, 2018. Spots are limited, so submitting as early as possible is important!
Attendee announcement: We will notify all applicants by late March whether they are on the 2018 camp attendee list.

You can complete and submit the Youth Camper application online (below) on a convenient and secure website.

If you would prefer, you can also download the application and email, fax or mail it to the Amputee Coalition. More instructions are included in the form itself and please feel free to contact us at camp@amputee-coalition.org or 888.267.5669.

download the application

Looking for Leadership Camp (18-19 year olds) or Camp Counselor Applications?

Camp Application

General Information


Parent/Guardian Information


Parent/Guardian #1

Parent/Guardian #2

Additional Information

Current or Past Medical Conditions/ Camp Support(s) Needed:

Please list any current or past medical conditions that may affect your child at camp (seizure disorder, diabetes, anxiety, etc.) and what support(s) are needed during camp to address the condition.

Condition/Diagnosis & Camp Support(s) Needed:
  Special Needs:
We encourage your child to be as independent as possible at camp. However, we understand that your child may need some assistance from time to time. Please complete the sections below to help us know how we can best serve your child.

Additional Camper Information:

e.x. Spiriva for Asthma, Administer once daily at 10am
Camper Travel Arrangements:

I understand that the Amputee Coalition will make all of the necessary travel arrangements and that the Amputee Coalition will cover the cost of airfare. I understand that the Amputee Coalition is responsible for arranging, rescheduling or canceling my flight. If I am unable to attend or needs to reschedule flights, I will contact the Amputee Coalition immediately and will be responsible for any fees resulting from a rescheduled flight or cancellation. I understand that I am responsible for my transportation to the airport. I am responsible for my child's baggage fees.

Please list the two closest major airports. To ensure the lowest airfare and most direct flight, you may need to drive up to 2-3 hours to get to an airport. 
Please indicate who will be picking up your child from the airport at the END of camp. You must inform the Amputee Coalition if this information changes.
I will fly with my child to the Cincinnati/Northern Kentucky International Airport and will be responsible for my airfare. I will schedule our flights to arrive at the airport by 1:00 pm, June 11th. I will pick up my son/daughter by 8:30 am at the airport on June 16th. The Amputee Coalition will designate a drop-off and pickup location at the airport. I am responsible for dropping off and picking up my child at the designated drop-off and pickup location at the airport. I understand that I am responsible for arranging, rescheduling or canceling my flight. I will provide my flight itinerary to the Amputee Coalition. I understand that if my child is unable to attend, the cost of my child's airfare will not be reimbursed. I am responsible for my child's baggage fees.                                                                                                                                                                                                                                                       The Amputee Coalition will reimburse my travel expenses up to $600 only if my child attend camp for the entire week and an email with itemized flight itinerary and receipt are provided by August 14, 2018.  
I will be responsible for dropping off and picking up my child at the location and time set by the Amputee Coalition. If I am unable to drop off/pick up my camper at the designated time or location, I will contact the Amputee Coalition staff to discuss options. The Amputee Coalition will reimburse my mileage up to $600 only if an email with mileage driven to camp is received by August 14, 2018.

Need assistance with this form?

Questions?
If you have any questions or concerns, please contact the Camp Director, Tonya Osborne-Simpson:
Email (preferred method): camp@amputee-coalition.org
Phone: 888/267-5669, x8103
Fax: 865/525-7917
Mail: Amputee Coalition, 900 E Hill Avenue, Suite 390, Knoxville, TN 37915