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

Transcription

1 CAMP In Motion Adaptive Sports Camp for Children with Cerebral Palsy June June July July Camper Application Name: Date of Birth: Male Female Address: City: State: Zip Code: Home Phone: Address: Parent Name (s): Parent Phone # (s): Secondary Emergency Contact (Name/Relationship): Secondary Phone Contact: I would like to receive pictures from camp: Yes No Use Above Referring Physician: Primary Care Physician: Phone: ( ) - Phone: ( ) - Please tell us how the cerebral palsy affects your child s ability to move: Please list other secondary diagnoses: (ie. asthma, autism, vision/hearing, breathing difficulties, heart trouble, bowel/bladder difficulties, difficulty eating, etc.) Please note, if cerebral palsy is not the primary diagnosis listed on the script, medical review will be assessed to determine therapeutic benefit for camp. Camp Week Choice (In order of preference, #1-4, if wishing to attend multiple weeks, please indicate by circling weeks - multiple weeks will be granted upon availability). We make every effort to have campers attend with peers or other campers of similar age in order to optimize your child s camp experience. The July camp will have a half day option for children 5-7 years old. June June July July 17-21

2 T-Shirt Size: Youth Small Medium Large Adult Small Medium Large X-Large Equipment: ARM ORTHOTICS: Left Right Daytime (type) Nighttime (type) LEG ORTHOTICS: Left Right Daytime (type) Nighttime (type) WHEELCHAIR: (% of time used) ASSISTIVE DEVICES: (% of time used) None None Manual Gait Trainer Camper Pushes Needs Help to Push Power Walker Camper Drives Needs Help to Drive Other Does your camper? Sit with minimal assistance or less: Yes or No Use at least one extremity with control: Yes or No Follow directions: Yes or No IF ANSWERING NO TO TWO OR MORE OF THE ABOVE QUESTIONS, IT IS ADVISED THAT AN ATTENDANT BE PRESENT WITH CAMPER DURING CAMP. Please circle one: Can the camper walk independently? Yes or No What does the camper use for long distance? Walker or wheelchair Can the camper get in and out of the wheelchair independently? Yes or with 25% 50% 75% 100% assistance Can the camper sit independently? Yes or with 25% 50% 75% 100% assistance Can the camper hold a ball? Yes or No Can the camper throw a ball? Yes or No Can the camper kick a ball? Yes or No Can the camper swim independently? Yes or with 25% 50% 75% 100% assistance

3 Would you like to be contacted about future adaptive sports programs by either Dell Children s Medical Center or the YMCA of Austin? Yes or No Medical History: Does the camper have a history of seizures? If yes, please list frequency, presentation, and treatment plan. How does the camper communicate? Talks, Sign Language, Communication device, Other: Does the camper have any hearing or vision deficits? If so, please list: Does the camper have any difficulty with or need help with self-feeding? If so, please list: Does the camper have any allergies? If yes, list allergies. Is the camper currently taking any medications? Please list medications taking:. Please indicate level of skill with the following areas: Dressing/Changing to Swim: Independent Needs Help Dependent Transfers: Independent Needs Help Dependent Toileting: Independent Needs Help Dependent Does the camper have any behavior or attention problems that could interfere with his or her ability to participate? If yes, what treatments is he or she receiving?

4 What type of positive reinforcement is most effective with your child? Praise, reward, etc. What type of motivation is most effective with your child? Has the camper had any prior sports training? If so, please explain. What are the camper s goals for camp? Any additional information the staff should know about your child prior to attending Camp In Motion? Campers will undergo pre and post assessments of strength, endurance, balance, and self-esteem. Documentation will be completed on the progress of each camper throughout the week. It is strongly recommended that campers take a break from their current therapies during the week(s) he or she is attending camp in order to improve quality and consistency of camp experience. The cost of Camp In Motion is $765/week or $153/day. Financial assistance is available. There is a non-refundable deposit of $150 that will be applied to camp tuition. Billing for the camp will be done through Dell Children s Medical Center. Accounts and the cost of camp will first be billed through your insurance company. Claims will be submitted through your insurance company, but this does not guarantee payment. If your insurance company denies the claim, you will be responsible for the bill. Financial assistance will be available. YMCA support staff are available to discuss and work out payment plans Please complete the following insurance information and attach a copy of your medical insurance card for pre-authorization. Insurance Carrier:

5 ID # Group# Subscriber s Name Cancellation Policy: Due to registration demands, Camp In Motion will require all cancellations occur two weeks prior to start date of camp, or will forfeit the initial deposit of $150. Media Release Form Media/Photo Waiver: I hereby authorize and give my full consent to Dell Children s Medical Center and the YMCA of Austin, to copyright and/or publish any and all photographs, videotapes and/or film in which the camper appears while attending Camp In Motion. I further agree that these entities may transfer, use or cause to be used, these photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes, and television programs without limitations or reservations. WAIVER, RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT: I understand that YMCA activities have inherent risks and in consideration for participating in Camp In Motion I hereby assume all risks and hazards incident to my participation in all YMCA activities, due to the negligence of the YMCA or otherwise while in, about, or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA, including volunteer service. I further waive, release, absolve, indemnify and agree to hold harmless the YMCA, the organizers, volunteers, supervisors, officers, directors, participants, coaches, referees, as well as, persons or parents transporting participants to and from activities from any claims or injury sustained during my use of the YMCA property or participation in programs. Parent/Guardian Signature Print Name Date All campers need to have this prescription signed by his or her physician for medical clearance to participate in Camp In Motion. This prescription can be signed by a primary care doctor or specialist. Please return this document with the completed application.

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