2016 Junior Wheelchair Sports Camp July 11-15, 2016

Transcription

1 2016 Junior Wheelchair Sports Camp July 11-15, 2016 For youth athletes ages 6-19 with physical disabilities who use a wheelchair or could use a wheelchair to participate in sports such as basketball, rugby, tennis, swimming, racquetball, climbing wall and MORE! Camp provides recreational and competitive opportunities for all the athletes. NO FEE for camp or transportation thanks to generous support from Cottage Rehabilitation Hospital Foundation! Camp Schedule: Monday-Thursday, 9:30 am 4:30 pm Friday, 10:30 am 6:30 pm Camper Qualifications Be between the ages 6 through 19 Have the desire to learn about, and participate in, adaptive sports Live with a physical disability which primarily impacts mobility Be able to mobilize a manual or power wheelchair Have functional use of upper extremities to be able to grasp an object Have the ability to communicate needs and direct others in meeting individual needs/accommodation Have the ability to attend to and participate in activity for a minimum of 15 minutes Be independent, or require set-up/supervision with bathroom and feeding skills or bring an attendant/caregiver to assist; must have awareness of or ability to, maintain bowel & bladder continence if planning to swim Camp provides: Beginner to advanced instruction in a variety of wheelchair sports Physical conditioning that stresses improved strength, endurance and mobility Camp counselors and instructors with expertise in wheelchair sports Daily lunches for all campers and volunteers Transportation. See tentative schedule for pick up points. Sport Wheelchairs for use in sport sessions Transportation Provided from: Oxnard (Oxnard High School) Santa Maria (Robert Bruce School) Carpinteria To be determined Lompoc To be determined Santa Barbara To be determined Charlotte Colton Family & Friends Dinner & Awards Friday, July 15 th, 4:00 6:00 pm

2 Families and friends of campers are invited to join their camper to watch them demonstrate sport skills learned at camp and enjoy a sponsored dinner with the awards ceremony immediately following. For questions call (805) ext Please return enclosed packet by July 1 st, 2016 to: Rene Van Hoorn/Therapeutic Recreation Cottage Rehabilitation Hospital PO Box 689 Santa Barbara, CA rvanhoor@sbch.org Fax:

3 2016 Junior Wheelchair Sports Camp Registration Form Registration Deadline: July 1, 2016 Return Packet to: Forms to Return: René Van Hoorn Registration Form Photo Release Cottage Rehabilitation Hospital Physician Release (1) Cottage Waiver of Liability P.O. Box 689 Physician Release (2) Family Day Invite Santa Barbara, CA Consent to Treat Cell: Fax: Please Check One: New Camper Returning Camper Name Address First Last Nickname Number/Street City State/Zip Age Date of Birth / / Male Female Parent/Legal Guardian Name Home Phone Work Phone Cell Phone Emergency Contact (Other than parent/legal guardian) Name Day Phone Relationship T-Shirt Size: Youth: S M L Adult: S M L XL XXL TRANSPORTATION Does camper need transportation? Yes No If Yes, Bus Pick Up Location: Carpinteria Lompoc Oxnard Santa Maria Santa Barbara Pick Up Authorization: Person(s) authorized to pick up camper: If from out of town, would you like a list of possible hotels/lodging? Yes No

4 CAMPER INFORMATION: Name: Height: Weight: Grade (in Fall 2016): Camper s Diagnosis: Describe Disability: Camper s best method of mobility: Power Wheelchair Walks with Walker Walks without equipment Manual Wheelchair Walks with Crutches Other: Will camper be bringing his/her own wheelchair? Yes No Is camper able to push/operate his/her own wheelchair? Yes No How much help does camper need to transfer onto other wheelchairs, swim lift, equipment? Dependent Some assistance Independent Will camper be bringing an attendant? Yes No Attendant s Name: Phone #: (All attendants must be at least 16) TOILETING NEEDS (Please include a change of clothes for camper if needed) Does camper wear a diaper Yes No If Yes, why : Bladder: Does camper use a catheter? Yes No If Yes, Type of Catheter: Size of Catheter: Daily catheterization schedule: Amount of help camper needs to catheterize: If No, does camper know when they need to urinate Yes No Bowel Program Continent (able to control bowel movements): Yes No Daily Schedule: Assistance Level (check one): Dependent Some assistance Independent How much help does camper need to get on/off toilet and for toilet hygiene: OTHER NEEDS (Describe any other specific needs or consideration for camper to participate in sports) Limited movement or weakness in arms? Explain: Special communication needs? Explain: Special dietary restrictions? Explain: Please describe any other specific needs for your camper: Is Camper allowed to swim? Yes No Has camper ever taken swim lessons? Yes No If yes, where? If no, has camper ever been in a pool? Yes No Parent/Guardian s Signature (If Camper under 18) Camper s Signature (If Camper over 18) Date Date

5 Junior Wheelchair Sports Camp: July 11 15, 2016 Physician Release Form: Part 1 Page 1 To be completed by PARENT (Unless camper is 18 years or older) Camper s Name: Date of Birth: MEDICAL INFORMATION (to be completed by Parent and approved by Physician) Medications camper takes, include dose & frequency: Allergies: Be specific (i.e., food, sun, bee stings, latex). Please send epipen or medication used (i.e., Benadryl) for all allergies: Please outline any Medical Conditions (i.e. seizures*, asthma, diabetes, allergies, heart conditions) that may affect the camper s ability to participate in sports activities: * If camper has seizures provide details (i.e. types of seizures, frequency, what brings them on, pre/post behavior, date of last seizures & describe preferred treatment after seizure): List any Surgeries, or Medical Interventions/Hospitalizations that could impact participation in camp activities: Would you like the Camp Nurse to contact you directly before camp? YES If Yes, provide your name and best phone number: NO Primary Care Physician Name: Phone Number: JWSC Phys Release Form

6 Junior Wheelchair Sports Camp: July 11 15, 2016 Physician Release Form: Part 2 Camper Name: Page 2 To be completed by PHYSICIAN The above camper is planning on participating in the Junior Wheelchair Sports Camp held July 11 15, 2016 at UCSB Recreation Center coordinated by Cottage Rehabilitation Hospital. In order for us to best serve the needs of the camper please complete the following form. Campers participate from 9:00 am 4:30 pm daily in sports and recreation activities, which are adapted to each camper s specific needs and abilities. Activities include, but are not limited to wheelchair basketball, wheelchair tennis, wheelchair rugby, wheelchair racquetball, handcycling, and adapted aquatics/swimming. A rope s course and climbing wall are offered once during the week. Many activities involve some level of physical contact. If you need further information about these activities, please contact René Van Hoorn at ext , rvanhoor@sbch.org. Based on the activities and what you know about the camper s medical condition(s) i.e., spinal fusions, rods, shunts, etc., the camper is medically released to participate in this program. Initial YES NO Comments: Physician Information Name (printed): Signature: Address: Date: Zip: Phone: Complete and return form with packet to: René Van Hoorn OR FAX the form to: Cottage Rehabilitation Hospital FAX # P.O. Box 689 Phone ext Santa Barbara, CA rvanhoor@sbch.org JWSC Phys Release Form

7 Authorization For Third Party To Consent To Treatment Of Minor Lacking Capacity To Consent In the event of an emergency, we, the directors of the Junior Wheelchair Sports Camp, will attempt to contact you (the parent or legal guardian of the child) immediately. However, should we be unable to contact you, and should we deem it necessary, we will take the child to the emergency room at the local hospital and have medical attention given to the child. We will continue to attempt to reach you while at the emergency room. This form will authorize us to have that emergency care given under those circumstances. I/We, the undersigned parent(s)/person having legal custody/legal guardianship of, a minor, do hereby authorize the directors of the Junior Wheelchair Sports Camp as agents for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by a physician is licensed under the provisions of the California Medical Practice Act and on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority to power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which a physician, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable. This authorization is given pursuant to the provisions of Section 6910 of the Family Code of California. I/We hereby authorize any physician and/or hospital which has provided treatment to the above-named minor pursuant to the provisions of Section 6910 of the Family Code of California to surrender physical custody of such minor to my/our above-named agent(s) upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California. These authorizations shall remain effective through July 15, 2016 unless sooner revoked in writing delivered to the director of the Junior Wheelchair Sports Camp. Date Parent/Legal Guardian/Person having legal custody If signed by other than parent, indicate relationship: JWSC Consent to Treat Auth 2016

8 WAIVER OF LIABILITY, ASSUMPTION OF RISK & INDEMNITY AGREEMENT ELECTIVE/VOLUNTARY ACTIVITIES WAIVER Waiver: In consideration of being permitted to participate in any way in Santa Barbara Cottage Hospital - Cottage Rehabilitation Hospital Junior Wheelchair Sports Camp Hereinafter called The Activity, I, for myself, my heirs, personal representative or assigns, do hereby release, waive, discharge, and covenant not to sue Cottage Health System and Santa Barbara Cottage Hospital - Cottage Rehabilitation Hospital its officers, employees, and agents from liability from any and all claims including the negligence of Cottage Health System and Santa Barbara Cottage Hospital - Cottage Rehabilitation Hospital its officers, employees and agents, resulting in personal injury, accidents, or illnesses (including death) and property loss arising from, but not limited to, participation in The Activity. Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions 3) catastrophic injuries including paralysis and death. I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD Cottage Health System and Santa Barbara Cottage Hospital - Cottage Rehabilitation Hospital HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney s fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred. Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. *If the participant is a minor, his or her custodial parent or legal guardian must read and execute this agreement. I hereby warrant that I am the legal guardian or custodial parent of the participant who is a minor, and agree, on my own and said minor s behalf to the terms and conditions of the foregoing agreement. Date Age (if Minor) Print Name of Participant Signature of Patient/Guardian of Participant if Minor Print Name of Parent/Guardian of Participant if Minor WAIVER OF LIABILITY, ASSUMPTION OF RISK & INDEMNITY AGREEMENT ELECTIVE/VOLUNTARY ACTIVITIES WAIVER WHITE File CANARY Participant < Form# goes here> (10/10)

9 Consent to Photograph or Videotape Please note that this consent form must be signed before photography or filming begins. The undersigned hereby authorizes Cottage Health System and/or the attending physician to photograph or permit other persons to photograph: (NAME of person being photographed/filmed HERE): The undersigned agrees that Cottage Health System and/or the attending physician may use and permit other persons to use the negatives, photographs or film for purposes including, but not limited to, dissemination to hospital staff, physicians, health professionals and members of the public for educational, research, scientific, marketing, and/or charitable purposes. This photography/filming is intended for the following circumstances: For Cottage marketing and advertisements, including videos, Web site and Facebook page, print advertising and Cottage print publications, TV broadcast for commercials and Telethon. Dissemination of the photography/filming may be accomplished in any manner and such use is subject only to the following limitations: Cottage marketing and communication purposes only. The undersigned and his/her successors hereby waives any right to compensations for such uses and holds Cottage Health System and/or the attending physician and their successors harmless from any claim for injury or compensation resulting from the activities authorized by this agreement. The term photograph, as used in this agreement, shall mean motion picture or still photography, as well as videotape, video disc, electronic, audio media and any other mechanical means of recording and reproducing images or voice. At any time during the photography or filming, the undersigned has the right to request cessation of such activity and has the right to rescind consent for use up until a reasonable time before the recording or film is used by contacting the public affairs department, (805) Time/Date Signed Location Witness ADDRESSOGRAPH Consent to Photograph or Videotape Permiso para Fotografiar o Grabar en Video Form# NS-916 (Rev. 05/11)

10 2016 Junior Wheelchair Sports Camp Charlotte Colton Family & Friends Day Friday, July 15 Dinner & Award Ceremony Invitation All families are invited to join your camper any time after 1:00 on Friday, July 15 Dinner provided for campers and their families Dinner and Awards to begin at 4:30! Yes family will be able to attend; number attending: No family will NOT be able to attend To best schedule camp buses, will your camper need a camp bus to transport them to and from camp on Friday, July 15? Yes, both to and from camp Yes, to camp only (we will provide transportation home) No, we will provide transportation both to and from camp No, camper is unable to attend camp on Friday, July 15 Camper Name: Please return this form with Camper Packet JWSC Family Day Invite 2016