Camp Sun N Fun 2016 Application

Size: px

Start display at page:

Download "Camp Sun N Fun 2016 Application"

Juliet Curtis
5 years ago
Views:

Camp Sun N Fun 2016 Application CAMPER INFORMATION 1036 N. Tuckahoe Rd. Williamstown, NJ 08094 856-629-4502 P 856-875-1499 F camp@thearcgloucester.

Relationship: Address (If Different): City: State: Zip: E-Mail*: *Please be sure to include e-mail if you wish to be included in our Family/Friends Facebook page for photos and updates on your

1 Camp Sun N Fun 2016 Application CAMPER INFORMATION 1036 N. Tuckahoe Rd. Williamstown, NJ P F camp@thearcgloucester.org First Name: Last Name: Nickname: Birthdate: Age: Gender: Address: City: State: Zip: County: Municipality: Home Situation: Family Home Skilled Sponsor Group Home Other APPLICATION CONTACT Name: Relationship: Address (If Different): City: State: Zip: *: *Please be sure to include if you wish to be included in our Family/Friends Facebook page for photos and updates on your campers stay. Cell Phone: Home: Work: EMERGENCY CONTACTS Must be two different people than the application contact. The persons listed should be made aware that they will be responsible for your camper in the event of an emergency or they need to leave camp for any reason. 1. Name: Relationship: Address: City: State: Zip: Cell Phone: Other Number: 2. Name: Relationship: Address: City: State: Zip: Cell Phone: Other Number: ADDITIONAL CONTACTS Legal Guardian: Phone: Primary Care Physician: Phone: Support Coordinator/Caseworker: Phone: Check One: o DDD (Adults) o DCF/ PerformCare (Children) o DCP&P/ former DYFS o Other School/Work/Day Program: Contact: Phone Number: Number of Years Attended:

2 CAMPER SUMMARY Camp Experience CAMPER NAME: Camped Here Before: Y N How Many Years: Other Camps: Diagnostic Information Diagnosis: Onset: Circle One: Mild Moderate Severe Allergies (Drug & Food): Expected Reactions: Epi-Pen: Y N Additional Comments: Seizure History: Y N Type: Seizure Frequency: Typical Seizure Duration: What Precedes a Seizure: Diastat (rectal diazepam): Y N Vagus Nerve Stimulator (swipe): Y N Dietary Information Please be sure to send enough of items like Ensure and Thick-It for the length of your campers stay. Special Diet: Swallowing Difficulties (Straws, Consistency): Adaptive Eating Devices: Comments: Sleep Routine Camper Sleeps: PM to AM Skills Assessment Awakens At Night: Y N Why: Check the box that applies for each category. Speech Communication Mobility Hearing Vision Normal Normal Speech Normal Normal Normal Mildly Affected but Few Spoken Words Affected Independent Mild Loss Mild Loss Severely Total Sign Language Assistance Total Loss Affected Loss Non-Verbal Communication Device Gestures Check the box that applies for each category. Cane/Walker Hearing Aid Glasses Wheelchair Cochlear Implants Eating Dressing Bladder Bowel Aids Independent Independent Normal Normal Moderate Assist Cutting Finger Foods Total Assist Moderate Assistance Total Assistance False Eyes Diapers/Pull Ups Accidents Accidents Toilet Chair Incontinent Incontinent Shower Chair Shower Cradle

3 Please write in the appropriate letter next to each box. Use the following abbreviations: Good = G Fair = F Poor = P Motor Recreational Social Behavior Balance Sports Small Groups Abusive to Self Hand Control Creative Activities Large Groups Abusive to Others Use of Pen/Pencil Swimming Self-Control Wanders/Elopes Hand/Eye Music Motivation Destroys Property Nature Activities Basic Directions Frustration Interaction w/ Peers Homesickness Does your Camper have a current behavioral plan? Y N If so you must attach a copy to this application. *All adaptive equipment must be provided such as diapers, floating devices, mobility aids, eating equipment, communication tools. ALL CAMPERS WHO WEAR DIAPERS ARE REQUIRED TO BRING A SWIM DIAPER. Hygiene Assistance Levels (Check applicable boxes) Showering Toileting Shaving Teeth/Dentures Menstruation None/Minimal Moderate Total Not Applicable Does your camper have teeth? Y N Dentures? Y N My camper requires the following overall level of assistance: (Circle One) Minimum Moderate Total Insurance & Medication Information Primary Insurance Co.: ID #: Phone: Secondary Insurance Co.: ID #: Phone: Medications (Include any Routine OTC Medications, use another page if necessary) Medication Route Dose Frequency Reason Special Administration Instruction: CRUSH - APPLESAUCE - OTHER:

4 SESSION REQUESTS Please indicate session choice by order of preference using 1,2 3 for first, second and third choices. Please keep in mind as you start to plan your respite time that although we make every effort to honor your requests we cannot guarantee you will get the session(s) of your choice. We will do our best to accommodate your Extended School Year needs on a first-come-first-served basis. Residential Camp Sessions Session 1 June 26 July 1 Session 2 July 3-8 Session 3 July 10 22** Session 4 July Session 5 July 31 Aug 12 Session 6 Aug **Christmas in July, July 22 I request sessions in total. Day Camp Sessions Session A June 27 - July 1 Session B July 4-8 Session C July Session D July Session E July Session F Aug 1-5 Session G Aug 8 12 Session H Aug TUITION CALCULATION & PAYMENT Registration Fee (non-refundable) $50.00 X 1 = $ Resident Camp 1 Week Session Total Assistance 1 Week Session Resident Camp 2 Week Session Total Assistance 2 Week Sess. Day Camp Session Total Assistance Day Camp Sess. Total Tuition: $ X = $ $ X = $ $ X = $ $ X = $ $ X = $ $ X = $ $ *Checks and Money Orders should be made payable to The Arc Gloucester Method of Tuition Payment Mark an X next to the appropriate method of payment for your camper. Please check more than one if payment will be coming from two different sources. Camper/Family Paying $ DDD (Adults) $ DDD Thru Real Life Choices $ DDD Thru Self Directed Services $ DCF (Children) $ CSOC/PerformCare (Children) $ DCP&P $ Other (Civic Org, etc.) $ *All camper/family payments must be 50% paid within 30 days of receipt of your acceptance letter and invoice. Final payment must be made by June 15 th. No camper will be allowed to attend camp without tuition paid in full. We understand that we will not receive payment from DDD, CSOC and some other sources until after their stay. It is your responsibility to request written documentation from the payment source and provide to us within 30 days of acceptance and invoice.

5 Payment Plans Payment plans are available on an individual basis. All payment plans must be followed as agreed upon and final payment must be made before September 30 th. Please check below if you are interested in a payment plan and contact the camp secretary at to arrange terms. I would like to be considered for a payment plan for 2016 camp tuition. Financial Aid Financial aid is available on a limited basis for campers in family homes through grants and the Stephanie B. Furrer Foundation. Please indicate below if you would like to be considered for financial aid. Complete the attached form and submit all supporting documents. I would like to be considered for financial aid for 2016 camp tuition. How did you hear about Camp? ADDITIONAL COMMENTS (please use space below to add further details for your appl.) APPLICATION SIGNATURE I have completed and reviewed the information I wrote on this application and know it to be true to the best of my knowledge. I understand that if I do not fully complete the application or submit all required components it will be placed on hold and no session will be reserved. I have received and reviewed the attached Camp Sun N Fun Family Handbook. I am fully aware of and understand the policies and procedures and I will use it as a guide through the application process as well as abide by them. I understand that if I or my camper do not abide by the policies and procedures outlined in the handbook it may result in their being sent home early from camp. Signature of Applicant APPLICATION PROCESSING DETAILS OFFICE USE ONLY App Rec d: Reg Fee Rec d: Y N Pulled from Hold: Tour Needed: Hold: Y N Y N Accepted: Session #: Cabin #: Level of Assistance: Minimal Moderate Total Admin Initial:

6 PERMISSIONS SECTION Must be signed parent/legal guardian only, skilled sponsors and group home staff signatures are not acceptable. If guardianship status is undecided please let us know at the time of your application. Authorization to Participate & Permission for Emergency Treatment (Required) I feel this applicant is appropriate for camp and give my permission to participate in all camp activities, except as specifically noted herein. In the event of an emergency I hereby give my permission for the camp administration to provide and/or secure medical treatment for the camper named in this application. Waiver (Required) I hereby give my permission for my applicant to attend Camp Sun N Fun. While camp will take every reasonable precaution, it is agreed that Camp Sun N Fun assumes no responsibility for the camper s personal property and it is released from liability in connection with medical costs, except as covered by camp s insurance. Prescription Medication (Required) I hereby give my permission for Camp Sun N Fun to administer the prescribed medications listed in the Insurance and Medication Information Section of this application according to the directions given by the physician on the medication containers. Over the Counter Medication (Required) I hereby give permission for Camp Sun N Fun to administer over the counter medications to my camper as needed with the exceptions listed on the allergy section of this application according to the directions by the manufacturer as well as the standing orders of the camp doctor. Public Relations (Optional) Permission is hereby granted to use my camper s name and photograph in different media outlets to publicize the work and program of The Arc Gloucester s Camp Sun N Fun.

CAMP In Motion Adaptive Sports Camp for Children with Cerebral Palsy June June July July Camper Application

CAMP In Motion Adaptive Sports Camp for Children with Cerebral Palsy June 12-16 June 19-23 July 10-14 July 17-21 Camper Application Name: Date of Birth: Male Female Address: City: State: Zip Code: Home