Leadership Camp Application

For young adults living with limb difference or limb loss in the United States and aged 18-19, the Amputee Coalition created Leadership Camp as a development opportunity. If you are interested in a camp experience combined with leadership development, please complete the application below. All travel and camp expenses are covered through the generous support of our donors.

Camp:  July 8-13, 2019
Deadline:  March 1, 2019. 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 2019 Leadership Camp attendee list.

You can complete and submit the Leadership Camp 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

Leadership Camper Application

General Information


Emergency Contact


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

References: List two non-family references, one that you have known for at least one year.

Work History: Be sure to include any experience working with youth or in a camp setting, and any volunteer work. Attach separate sheet if needed.
Employer 1
Employer 2
Employer 3

Background Check:

We will run a criminal background check on all leadership campers.

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, am dismissed from camp, or need to reschedule my flight, 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 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.
 

I understand that I am responsible for arranging, rescheduling or canceling my flight. I will schedule my flight to arrive at the Cincinnati airport. I will provide my flight itinerary to the Amputee Coalition. I understand that if I am unable to attend, am dismissed from camp, or need to reschedule my flight I am responsible for the cost of my airfare.

I am responsible for my baggage fees.

 

The Amputee Coalition will reimburse my travel expenses up to $600 only if I attend camp for the entire week and provide an email with itemized flight itinerary within 30 days of camp.

I will be responsible for my own transportation to Camp Joy. I understand that I must arrive by the time set by the Amputee Coalition. If I am unable to arrive 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 within 30 days of camp. The Coalition will not reimburse counselors if they are dismissed from camp.

Additional Information: Please tell us more about yourself!

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