All forms and the $25.00 registration fee must be completed and returned to us in order to start the enrollment process.

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1 PineTree oce~ DI SCOVERING A B I L IT I E S TOGE THER Dear Parents and Guardians: Thank you for your interest in having your child attend Camp Pine Cone in Many of last year's summer staff members will be returning and are looking forward to another safe, enjoyable and memorable season on North Pond. Your application for the 2012 season is enclosed. Please read the below information carefully. P.O. Box Front St. Bath. ME U.S. Roule I Suite B Scarborough. ME Pine Tree Rd. Rome. ME Important notes about the application packet The enclosed application packet includes: Four-page Camper Application Two-page Health History Child Camper Eligibility Return envelope All forms and the $25.00 registration fee must be completed and returned to us in order to start the enrollment process. Changes in the summer schedule Camp Pine Cone will be running only two weeks. These sessions will run consecut ively with the Pine Tree Camp children's sessions four and five. Camper enrollment Campers are enrolled on a first-come, first-served basis. A total of 15 camper slots per session will be available in Session assignments for applicants will be made at my discretion, in consultation with parents and other concerned parties. My goal is to schedule campers into the sessions that are most appropriate and enjoyable for them. Application process questions and additional details If I should need additional information to process the application, I will contact you at the telephone number/s you provide. All applicants will receive a follow-up letter indicating that they have been accepted or have been placed on a waiting list (if the application is processed/ received after all available slots have been filled). Should your child be accepted to camp, we will need your primary care physician/family physician to conduct a physical exam of the applicant and complete the Physical Examination form. (Please note: Campers will receive this form with their acceptance letter, it is not included in this mailing.) If you have any questions or concerns, please contact me at the telephone numbers or address listed on the application. In closing, I wish you all the best in the year ahead. Sincerely, Dawn Willard -Robinson Director Pine Tree Camp W I\' W. p i n e I r e c SOC i e t f. 0 r g

2 For office use only Date Received Session # Deposit Received Check Number Accpt. Ltr Please print or type Camper Information A program of Pine Tree Society 2012 Camper Application Camper name Last First Initial Street City State Zip Phone Number Date of Birth MM DD Year Family Information Parent s Name If different from above Place of Employment Parent s Name If different from above Place of Employment Guardian s Name If different from above Place of Employment Emergency Contact Information 1. Name Relationship to camper 2. Name Relationship to camper

3 Camper Information Camper s disability (please be specific) Educational History (Please note grades completed and schools attended) Camper attitude about camp Parent attitude about camp Has camper attended camp before ( Y / N ) When and where Camper Health Questions Movement: Walks on their own Walks with braces Uses walker Uses cane Uses wheelchair Chair is electric Can drive electric chair ( Y / N ) Chair is manual Can push manual chair ( Y / N ) camper can get in and out of chair without help ( Y / N ) Personal Care: Dresses self ( Y / N ) Feeds self ( Y / N ) Bathes self ( Y / N ) Will require one-on-one care/supervision ( Y / N ) Toileting: Does camper have bladder control ( Y / N ) Bowel control ( Y / N ) Use catheter ( Y / N ) Self cath ( Y / N ) Ileo bag ( Y / N ) Wet the bed ( Y / N ) Wears Depends ( Y / N ) Does camper have bowel regime ( Y / N ) Personal grooming ( Y / N ) Communication: Speech or language problem ( Y / N ) Hearing problem ( Y / N ) Hearing aid ( Y / N ) Visual impairment ( Y / N ) Uses glasses or contact lenses ( Y / N ) Seizures: Have seizures ( Y / N ) Type ( Grand Mal / Petite Mal ) Date of last seizure Please note: Camper must be on a stable seizure medication regime and not in the process of changing medication or altering the dosage of current medication for at least one month prior to camp. General: Food Allergies ( Y / N ) Allergies to insects, animals, plants ( Y / N ) Medicine Allergies ( Y / N ) Special Diet ( Y / N ) Current Immunizations ( Y / N ) Current Tetanus shot (date) Any activities camper cannot take part in ( Y / N ) Have a shunt ( Y / N ) Recent illnesses, surgery or hospitalization ( Y / N ) History of behavioral problems ( Y / N ) Taking medication for depression ( Y / N ) Recent family loss or other cause for depression ( Y / N ) Please explain any Yes answers from above

4 How did you hear about Camp Pine Cone? Camper Tee Shirt Size: Person completing this application Name Signature Relationship to camper Phone number Please note: the applications are accepted on a first-come, first-served basis. Release Information (please initial and sign) Date I hereby certify that I am the parent/guardian of the above named camper. I consent to the participation of the camper in all normal camp activities which the staff believe to be appropriate for his/her physical condition. I further consent to allow the camp staff, operating under the camp nurse, administering to the camper those regular medication which have been prescribed for the camper. In case of medical emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give permission to the medical personnel selected by the Camp Director to order X-Rays, routine tests, treatment and other emergency care necessary; to release any records for insurance purposes; and to provide or arrange necessary related transportation for the named camper. I hereby affirm that I am the parent/guardian of the above named camper and I hereby give my consent that photographs, videos, and/or stories of his/her or any reproduction of same, may be used by the Pine Tree Society, or by others with the consent of the Pine Tree Society, for the purposed of illustration or publication in any manner. Name Signature Relationship to camper Camper session assignments will be at the discretion of the camp director in consultation with parents, campers, and other concerned parties. Your acceptance letter will indicate which session you will be invited to attend Summer Schedule Session 8: July 16 to 20, 2012 Session 9: July 23 to 27, 2012 Pine Tree Camp (before May 15) P.O. Box 518, Bath, ME phone fax ptcamp@pinetreesociety.org (after May 15) 114 Pine Tree Camp Rd, Rome, ME phone fax ptcamp@pinetreesociety.org

5 Financial Information The actual cost per camper attending Camp Pine Cone is $ per 5-day session. The fee includes all activities, a T-shirt and snacks. Campers are to bring bag lunches. Each session will close with a family social. Please note: A $25.00 registration fee is required to reserve enrollment at Camp Pine Cone. Payment Information: For your convenience, Camp Pine Cone payments may be made securely on-line using a credit card. Simply visit and click Pay Tuition Online. You may also send payments to: Pine Tree Society, P.O. Box 518, Bath, ME Funding Source If the camper is eligible for respite or other funding for state, civic, religious or private agencies, please apply to these agencies and let us know the following information. Contact name Title Agency Phone Amount requested Anticipated date when you will hear back from them Please return this application to Pine Tree Camp Director: Before May 15 After May 15 P.O. Box Pine Tree Camp Road Bath, ME Rome, ME

6 Before May 15 PO Box 518 Bath, ME phone fax After May Pine Tree Camp Rd, Rome, ME A program of Pine Tree Society phone fax Camper Health History Form Part 1 This form to be completed by parent or guardian Camper s Name Sex Birth date Age Home Address Phone Number Emergency Contact Information Custodial Parent/Guardian Phone Number Address Business Address Phone Number Second Parent/Guardian/Emergency Contact Phone Number Business Address Phone Number If not available notify Phone Number Address Business Address Phone Number Medical Insurance Information Is the participant covered by family medical/hospital insurance? ( Y / N ) If yes, Carrier of Plan name Group # Carrier Address Name of Insured Relationship to participant Is the plan a Managed Care Program? ( Y / N ) If yes, Carrier or Plan Name Group # Name of Primary Care Physician Phone Number Address Medicaid/Medicare Information Since Maine Medicaid is now managed care, it is imperative that the following information be provided as accurately as possible. I participate in a Managed Care Program for my Medicaid I do not participate in a Managed Care Program for my Medicaid Name of Managed Care Carrier Carrier Address Policy/ID # Group # ** Medicaid/Medicare # Primary Care Physician Address Phone Number ** A current Medicaid/Medicare card must be presented during registration

7 Health History Form Part 2 Specific Disability Secondary Disability General Which of the following has the camper had? Check and give the appropriate dates. Measles German Measles Chicken Pox Mumps Hepatitis Varicella Zoster Convulsions Diabetes Frequent Ear Infections Mononucleosis Bleeding/Clotting Disorders Allergies/Diet Medication (Please be specific) Food Allergy (Please be specific) Dietary Modification Seizures Does camper have seizure? ( Y / N ) Under control with medication ( Y / N ) What type of seizure Duration of seizure How often Date of last seizure Please note: Camper must be on a stable medication regime. He/she should not be in the process of changing or altering the dosage of medication for at least a month. Activities Activities to be restricted (Please list) Activities to be encouraged (Please list) Parent/Guardian Authorization This health history is correct and complete as far as I know and the person herein described has permission to engage in all camp activities except as noted. Signed Printed Name Date Please note: If an outbreak occurs, the state health services will immunize the camper without your permission if the immunization history is not complete.

8 Camp Pine Cone Child Camper Eligibility Policy Please read and return this form with the camper s completed application. To be eligible to attend a session at Camp Pine Cone, a program of Pine Tree Camp, a child must meet all of the following requirements: The child must: Be between of 5 and 12 years of age. Have a diagnosis of physical or developmental disability. Be able to interact with others, be cognitively aware that he/she is participating in a camp program, be able to be involved in activities with other campers and respond to staff. Be able to adapt to the group living environment of camp without disrupting others during sleeping hours, meals and program activities. Be free of inappropriate sexual behavior. Be able to adapt to a staff supervision ratio of 1 staff to 3 campers. We are prepared to provide One-on-One care when needed for feeding, bathing, toileting, etc., but WE DO NOT HAVE THE RESOURCES TO SERVE CHILDREN WHO REQUIRE CONSTANT ONE-ON-ONE CARE THROUGHOUT THE DAY. Be free of emotional outbursts and capable of being able to restrain himself/herself at all times. WE CANNOT ACCEPT A CHILD WHOSE BEHAVIOR MAY REPRESENT A DANGER TO HIMSELF/HERSELF OR OTHERS. Be toilet trained, unless there is a valid medical reason for incontinence. We are prepared to assist campers who have limited bowel and bladder control due to their medical condition/s and are also prepared to deal with occasional accidents. WE ARE UNABLE, HOWEVER, TO ACCEPT CAMPERS WHO ARE SIMPLY NOT TOILET TRAINED AND ARE UNABLE TO ASK FOR HELP BEFORE SOILING THEMSELVES. Be free of medical conditions that, in the opinion of our medical staff, may represent a danger to himself/herself or others. Each applicant will be judged on an individual basis, but as a general rule, A CHILD IS NOT CONSIDERED A CANDIDATE FOR CAMP IF HE/SHE IS JUDGED TO HAVE A MEDICAL CONDITION ASSOCIATED WITH A HIGH RISK FOR COMPLICATION OR INJURY TO HIMSELF/HERSELF OR OTHERS. Be on a stable seizure medication regime and not in the process of changing medication or altering the dose of current medication for at least one month prior to arriving at camp. I meet the above criteria Yes No Name of camper: Signature of parent/guardian Date: