Creating solutions, changing lives. Services for children and adults with disabilities in Southern California

Transcription

1 2015 Creating solutions, changing lives. Services for children and adults with disabilities in Southern California Easter Seals Southern California 401 S. Ivy Street Escondido, CA (P) (F) Dear Parents and Campers, Thank you for your interest in Easter Seals Camp. This year s camp will be held August 2 nd through August 8 th at YMCA Camp Oakes in the San Bernardino Mountains. The title for this year s theme will be Camp University! Activities will include: swimming, Zip-line, canoeing, archery, arts & crafts, nature, campfires, a talent show, a special dinner and dance, and much more. The following forms are included in this packet: Camp Application (including authorization for emergency treatment) Financial Statement Camper Medical Form Donation Form and Guide To apply, complete the Camp Application and Financial Statement in full and return them as soon as possible. Incomplete applications cannot be processed and will be returned. After your complete application is received, you will be contacted by one of our volunteer camp directors so they may conduct a phone interview. Acceptance is determined after the paper application and phone interview are completed. After you are notified of acceptance, the Medical Form must be completed and returned. Please complete the medication section of the 2 page Medical Form and have the camper's doctor confirm those medications or update the list when you have your doctor's appointment. The Medical Form must be returned to Easter Seals prior to camp. Please list ALL medications, vitamins, supplements, etc. that you will be bringing to camp. Check in at camp will be delayed if there is a discrepancy between the Application/Medical Form and the items brought to camp. The fee charged to campers is $750. The actual cost per camper is $1,126 but Easter Seals subsidizes $376 per camper by raising donations. If you are able to pay more than the $750, we appreciate you doing so. If you have difficulty paying $750, we encourage you to solicit donations and some partial camperships are available. A donation guide and form are enclosed should you need assistance in soliciting donations. Regional Center will not cover the cost of Camp. Should you have any questions, please contact me at amanda.showalter@essc.org or Sincerely, Amanda Showalter Easter Seals Camp Director

2 Easter Seals Southern California 401 S. Ivy Street Escondido, CA RESIDENT CAMP APPLICATION Sunday, August 2nd thru Saturday, August 8th 2015 (PLEASE PRINT) Camper s Last Name First Name Nickname Camper s Diagnosis Conserved: Yes No ( ) Home Telephone Camper Address for official correspondence, if different Street Address City Zip M F Age Birthday Developmental Age Language spoken at home ( ) ( ) ( ) Primary contact Home Phone Work Phone Cell Relationship ( ) ( ) ( ) Secondary contact Home Phone Work Phone Cell Relationship ( ) ( ) ( ) Conservator s Name (if applicable) Home Phone Work Phone Cell/Pager Will parent/guardian/conservator be away from home during the camp week? Yes No If yes, where? Phone # ( ) In an emergency, if parent/guardian/conservator cannot be reached, notify: Name: Phone ( ) Relationship to Camper: Name: Phone ( ) Relationship to Camper: Name: Phone ( ) Relationship to Camper: 1 of 9

3 Doctor s Name Health Insurance Company Name Member # Phone ( ) Insurance Company Phone # Policy/Group # Allergies: None known Yes, Allergies to Medication. Name medication and describe reaction: Yes, other Allergies. Describe allergy and reaction: For all allergies, please list intervention (i.e. epi pen, inhaler, etc): If camper requires an epi pen, please bring it to camp. Seizures: Yes No If the camper has seizures, are they controlled: Yes No Are they: Petit Mal Grand Mal Last Occurrence: Frequency: Can Camper Predict? Yes No Triggers: Assistive devices (circle all applicable): Walker Wheelchair (Electric/Manual) AFO/Braces Glasses Magnet Helmet Communication Device Other: If the camper uses assistive devices, please describe any information that would be helpful to us: Immunizations Date of Tetanus Toxoid Date of D.P.T. (includes tetanus toxoid) Month Day Year or Month Day Year 2 of 9

4 PLEASE CHOOSE YES OR NO 1. Will camper take a wheelchair to camp? Yes No If yes, choose which type: electric manual If bringing electric W/C, you must also bring battery charger Can camper transfer? Yes No If yes, choose one: alone with assistance 2. Can camper walk alone? Yes No with assistance? Yes No use crutches? Yes No use walker? Yes No wear helmet for protection against falls? Yes No wear day braces? Yes No 3. Can camper climb stairs? Yes No 4. Can camper dress self? Yes No needs assistance with buttons? Yes No needs assistance with shoes? Yes No 5. Can camper feed self? Yes No If no, what help is needed? Does camper have difficulty swallowing? Yes No Can camper use regular eating utensils? Yes No Does camper need tray for wheelchair? If yes, please bring. Yes No 6. Does camper need assistance in toileting? Yes No needs to be lifted on/off toilet? Yes No needs assistance with toilet paper? Yes No needs assistance with clothing before/after? Yes No wears diapers daily/night only Yes No has accidents with bladder/bowel control? Yes No Indicates when he/she has to use toilet? Yes No has she started menstrual periods? (female only) Yes No 7. Are there specific foods the camper should not eat? Yes No If yes, list foods to be avoided and reaction to those foods 8. Rate camper s speech: Excellent Good Fair Poor (choose one) If fair or poor, how does camper communicate?

5 10. Does the camper take prescription medication? Yes No If yes, have the medications or dosages changed in the last three months? Yes No 11. Does camper have seizures? Yes No How much time is needed for recuperation after a seizure? 12. Does camper require special night care (e.g., turning, etc.)? Yes No If yes, specify: 13. Does camper have any pressure sores? Yes No 14. Does camper wear glasses? Yes No 15. Does camper use a hearing aid? Yes No 16. Does camper exhibit self-abusive behavior? Yes No 17. Does camper have dangerous tendencies that could result in harm to Yes No him/herself or others? If Yes, explain 18. Is camper taking medication? Yes No If yes, please list all medications (INCLUDING vitamins, supplements, etc.). Please provide a comprehensive list. strength/ Breakfast Lunch Dinner Bedtime Drug Name concentration 19. Does camper read? write? 20. What are camper s hobbies? 21. What activities does camper like best? 22. Is camper inclined to be outgoing? or shy and timid? 23. Has camper ever been separated from family before? Yes No If yes, how did camper react? 24. What are the most consecutive nights camper has been away from home? 25. Has camper been to another camp? Yes No How many years? Where?

6 26. Does camper follow directions well? respect authority? 27. Is camper able to work well within a small group? 28. Does camper sleep through the night? 29. Does camper know how to swim? 30. Please tell us about any limitations in use of arms, legs, hearing, sight and speech, also what disease or condition caused this limitation. 31. What group experience has camper had, i.e. scouts, church groups, social or sports groups? 32. Is there anything else you would like us to know?

7 Media Consent I give my permission for Easter Seals and anyone connected to Easter Seals to use any descriptions, stories, pictures, photographs, recordings of the person named above or things he or she says or does. Easter Seals may use these materials in print, broadcast, on the Web or any other medium and these may be released to the general public at any time. I give Easter Seals all rights to these materials. All of these materials made by Easter Seals are owned by Easter Seals and may be protected by a copyright. I also understand I will not be compensated in any way for use of the material Consent to Administer Prescription Medication I give permission for the camp nurse to administer the prescribed medications listed on the enclosed physician s form, per the doctor s orders listed on the prescription bottle/container. NOTE: All medications must be provided in original containers with unaltered labels Consent to Administer Over-The-Counter Medication I give permission for the camp nurse to administer over-the-counter medication if the nurse and/or consulting physician deem it necessary. Dosages will be administered according to age/weight per directions on the box/bottle unless a physician directs otherwise. Sample OTC medication and reasons for use below: Pain / fever or inflammation.tylenol/jr., Ibuprofen/Jr. Upset stomach, nausea Pepto Bismol, Tums, Maalox Diarrhea..Immodium AD Constipation Milk of Magnesium Insect / plant, skin irritations.calamine Lotion, Cortaid Minor allergy relief..benadryl/jr., Sudafed Cough / cold symptoms...robitussin, Chloroseptic Spray,Tylenol Cough & Cold/Jr. Motrin Cough & Cold/Jr. or equivalents Authorization for Emergency Treatment In case of medical or dental emergency, I/we understand every effort will be made to contact the parents/guardian/conservator of the individual (if applicable). If parent(s)/guardian(s)/conservator cannot be reached I/we authorize the Easter Seals and its' staff as agent for the undersigned, to obtain and consent to x-ray, examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered to said program participant under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital or by a dentist licensed under the provisions of the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist or at said hospital. I/We understand and agree that Easter Seals has no insurance covering such medical or hospital care. Costs incurred for such treatment shall be mine or my parent(s)/guardian(s)/conservator's sole responsibility. It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment or care being required but is given to provide authority and power on the part of Easter Seals, to give specific consent to any and all such diagnosis, treatment or care which a licensed physician or dentist in the exercise of their best judgment may deem advisable in an emergency. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California, and California State Education Code Section Personal Property The undersigned recognizes that neither Easter Seals nor the YMCA of Greater Long Beach/Camp Oakes can accept responsibility for camper s personal property. To reduce losses, the undersigned has ensured that a list of belongings has been attached to camper s luggage. I CONSENT/AGREE TO ALL OF THE ABOVE. Camper/Parent/Guardian/Conservator Signature Date Print Name If adult camper has a conservator, the conservator must sign all forms where signature is requested. If adult camper is legally responsible for him/herself, camper signs ALL signature lines where signature is requested. 6 of 9

8 EASTER SEALS SOUTHERN CALIFORNIA 401 S. Ivy Street Escondido, CA FINANCIAL STATEMENT The cost of sending a camper to Camp Oakes is $1,126. Easter Seals subsidizes every camper and the amount you are responsible for paying is $750. If you are unable to pay the full $750, campership funds are available, on a limited basis, for those who qualify based on income guidelines. All campers are encouraged to assist Easter Seals in raising funds by asking friends, neighbors and local businesses for contributions. A donation form is enclosed for campers who are able to raise donations. ======================================================================== Section 1 This section must be completed for all campers. Camper s Name: Check the following that apply: I will pay the full camp fee of $750. Payment is enclosed. I will pay the full camp fee of $750 and make an additional donation of I will need partial campership assistance. (Section 2 must be completed.) No refunds will be made if camper leaves camp because of homesickness, behavior problems or is sent home by the camp nurse. To pay by check, make the check payable to Easter Seals. To pay by credit card, circle one: Visa MasterCard Discover American Express Cardholder s Name (PRINT) Account Number Expiration Date Cardholder s Signature: TOTAL Amount to be charged: ======================================================================== Section 2 If you are requesting partial campership assistance. You will need to put your request in writing. Include your annual household income, the number of people who live in your house and the amount that you are requesting in campership funds. Please note that not all campership requests can be granted. Campership funds will be offered on a first come first served basis and Easter Seals will make every attempt to spread the money available around to as many campers as possible. - Without this information, campership funding cannot be granted. - A minimum payment of $400 is required for all campers receiving campership funding. Please send your written request for a campership with the other forms to Easter Seals via: Scan/ to camp@essc.org (preferred method) Fax to Mail to: Easter Seals Southern California, 401 S. Ivy St, Escondido, CA of 9

9 EASTER SEALS/ YMCA CAMP OAKES Camper Medical Form 2015 This form must be reviewed and signed by a physician. Return the form to Easter Seals by July 15, Scan/ to camp@essc.org (preferred method) Fax to Mail to: Easter Seals Southern California, 401 S. Ivy St, Escondido, CA Camper cannot attend camp without a completed and signed medical form before check-in day. Camper s Name: Medical Diagnosis: Medical History and Restrictions: 1) Has there been any recent exposure to a contagious disease or is the patient a carrier of a contagious disease? YES NO If yes, please explain. 2) How would you assess the applicant s current health? (CIRCLE) GOOD FAIR POOR 3) List any chronic health problems (e.g. asthma, pressure sores, cough, constipation) and treatments of which the medical staff should be aware: 4) Does the applicant have any known allergies? YES NO If yes, please describe. 5) Does the applicant have seizures? YES NO If yes, Current status: (i.e. active, controlled): Type of seizure: How often: 6) Has the applicant been hospitalized or treated in an emergency room recently? YES NO If yes, please explain. 7) Are there any physical conditions, past operations or injuries which should restrict camp activity? YES NO If yes, please explain and list any restricted area. 8) Please list any dietary restrictions. 9) Standing BP As needed medications: List any medications that are taken as needed (i.e. for headaches, heartburn, menstrual cycle) specifying the name of the drug, frequency and the corresponding dosage. *Please bring these medications. Drug Name Strength Dose Frequency 8 of 9

10 Scheduled Medications: (Oral Medications, Vitamins, Supplements: List ALL of the oral medications, vitamins, supplements camper is currently taking on a regular basis.) *Please bring these medications. strength/ Breakfast Lunch Dinner Bedtime Drug Name concentration Example Drug XYZ 1 pill = mg 1 pill NA 2 pills NA Liquid Medication 1 ml = mg 5 ml 5 ml 5 ml NA YES NO Do you give medications at any other times of the day or night? If yes, list medications and times. Please try to adhere to the administration times noted above, unless a medication must be given at a different time for medical necessity. PHYSICIAN S CONSENT AND SIGNATURE When seen by me on this date, the above named applicant was free from any contagious or infectious diseases or conditions and is capable of participating in the summer camp program(s) offered at Easter Seals/ YMCA Camp Oakes Physician Signature: Date: Physician s Name (Please Print): Office Phone: Emergency Phone: Address, City, State, Zip: 9 of 9

11 Final Check List Please be sure to submit the following forms: 1. Resident Camp Application (pages 1-7) 2. Medical Form (pages 8 & 9) The Medical Form must be completed and signed if you are notified that the camper has been accepted to attend camp. The Medical Form is reviewed and signed by a physician and does not need to be submitted with the other documents. The Medical Form must be returned to Easter Seals by July 15, TOTAL 7 pages (without Medical Form) TOTAL 9 pages (with Medical Form) Please submit the forms by one of the following methods: Scan/ to camp@essc.org (preferred) Fax to Mail to: Easter Seals, 401 S. Ivy Street, Escondido, CA For questions about camp, contact Amanda Showalter at Easter Seals at (951) or amanda.showalter@essc.org. Please note, applications that are not complete will be returned

12 Spring 2015 Dear Camper, Creating solutions, changing lives. Services for children and adults with disabilities in Southern California Donation Guide Easter Seals Southern California 401 S. Ivy Street Escondido, CA (P) (F) The fee to attend Easter Seals Camp Oakes is $750. If you qualify for a Campership the minimum cost is $400. Easter Seals understands that this expense may be difficult for some to incur. If this is the case, please consider soliciting donations as a means to cover these costs. In the past, many campers have solicited donations from businesses in their community that they often frequent. Some examples of this are banks, grocery stores, and churches. Many businesses have a Matching Gift Program, where an associate will make a donation and the business will match the money donated. Washington Mutual and Wal-Mart are two such places. My suggestion when asking for a camp donation from area businesses would be to: 1. Visit the store in person. 2. Ask to speak with the store manager or community relations department. 3. Tell them about Camp Oakes 4. Let them know how much camp means to you or how much you would like to attend. 5. Bring pictures of your past camp week, if you have them. 6. Share your favorite camp stories. In addition, many campers have turned to friends and family for donations. Ask an aunt, uncle, cousin, grandparent, your pastor and any close friends to donate $ $ These small donations will add up quickly. Is your birthday coming up? If so, ask for a donation to camp instead of a birthday present. If you have any questions, or need more suggestions on how to ask for donations, please feel free to call me or me at Amanda.showalter@essc.org I am more than happy to help guide you. Thank you, Amanda Showalter Coordinator of Camp Oakes

13 Easter Seals Southern California Donation Form CAMPER NAME: You Can Help! Please support children and adults with disabilities who cannot afford on their own to go to camp. This very special camp helps them enjoy, learn, grow and be challenged. Please make donations to: Easter Seals Resident Camp Program 401 S. Ivy Street Escondido, CA * Please reference camper s name. Resident Camp Activities: Crafts, boating, fishing, nature, archery, horseback riding, cooking, campfires, talent show, non-denominational chapels, special dinners, dances, and much more. Online Donation Credit card donations can be made at: When making the donation, please include camper s name you want to support. *If you are sponsoring a specific camper, please list camper name in the memo area of your donation check. *All donations should be clearly marked with your name, so that credit can be correctly applied. Sponsor/Donor Address Amount