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

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1 PLEASE RETURN CAMP APPLICATIONS BY OR IN PERSON TO: VALI MARTIN/CAMP IN MOTION COORDINATOR OAKCLAIRE DRIVE AUSTIN, TEXAS PHONE: PLEASE REFER TO WEBSITES FOR ADDITIONAL INFORMATION:

2 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: Referring Physician: Phone: ( ) - Primary Care Physician: Phone: ( ) - Campers will undergo pre and post assessments of strength, endurance, balance, and selfesteem. Documentation will be completed on the progress of each camper throughout the week. Please note that campers need to cancel their current therapies during the week(s) he or she is attending camp due to insurance restrictions unless paying out of pocket. The cost of Camp In Motion is $765 per week if paying out of pocket There is a non-refundable registration fee of $150 Financial assistance is available 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 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: 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 registration fee of $150. DOES YOUR CAMPER? Sit with minimal assistance or less: Yes No Use at least one extremity with control: Yes No Follow directions: Yes No IF ANSWERING NO TO TWO OR MORE OF THE ABOVE QUESTIONS, IT IS ADVISED THAT AN ATTENDANT BE PRESENT WITH CAMPER DURING CAMP.

3 If wishing to attend multiple weeks please indicate this by choosing weeks in order of preference, #1-4. Two week options will be available on a first come first serve basis. Additional weeks can be granted as available. 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 following dates are available for ages 7-21 year olds: June June July July The following half day option is available for children 5-6 years old: June 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: ASSISTIVE DEVICES: None None Manual Gait Trainer Camper Pushes Needs Help to Push Power Walker Camper Drives Needs Help to Drive Other What equipment is primarily used for mobility: Please indicate level of skill with the following areas: Dressing to Swim: Independent Dependent Needs Help With: Transfers: Independent Dependent Needs Help With: Toileting: Independent Dependent Needs Help With: Has the camper attended a camp before: YES NO What is the camper s therapy goal for camp? What is the camper s social goal for camp? MEDICAL HISTORY:

4 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 (Indicate if taking during camp day with asterisk):. 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. Please list three specific motivators for your camper: Example: particular song, stickers, youtube video, snack, etc Any additional information the staff should know about your child prior to attending Camp In Motion?

5 If we do not know your camper from a previous camp experience, please send a photo or video of your camper that shows his or her functional status. 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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7 Camper Packing List (English): Please bring the following items to camp every day in a backpack or tote bag. All clothing and other items that the camper brings should be clearly labeled with the camper s name or initials. Please do not bring money or electronic items. Please bring clothes that are appropriate for camp activities and the weather. Medication: Medication (all medications must be labeled in the original containers) Food: Packed lunch (If needed, please pre-cut food into sizes camper normally eats) Two snacks Water bottle that can be refilled throughout the day Any other drink the camper would like to have with lunch Clothes: Swimsuit Towel Swim Diapers Shirt (1 or more extra) Pants/Short (1 or more extra) Underwear (1 or more extra) Shoes (tennis shoes, please no sandals/flip-flops) Shoes (water shoes, wearing shoes in the pool is not required, but please bring shoes to wear walking out to the pool) Incontinence aids (if needed) Equipment: Braces/orthotics (please bring all that are utilized regularly) Assistive devices (if needed for general upright mobility) Wheelchair (if needed for regular mobility or fatigue) Other: Sunscreen

8 Lista de Empaque para el Campamento(Spanish): Por favor de traer los artículos en esta lista al campamento todos los días en un mochila. Toda la ropa y otros artículos deben estar etiquetados con el nombre o las iniciales de su niño. Por favor de no traer dinero o electrónicos (dispositivos para comunicación son bienvenidos). Por favor de traer ropa que sean adecuadas para las actividades del campamento y el clima. Medicación: Medicación (todos los medicamentos deben estar en el envase original y etiquetados con el nombre del camper) Comida: Almuerzo empacado Dos bocadillos Botella de agua que se pueda rellenar durante todo el dia Cualquier otra bebida que el participante quisiera tener con almuerzo Ropa: Traje de baño Toalla Pañales de Agua Camiseta (1 o más) Pantalones/pantalones cortos (1 o más) Ropa interior (1 o más) Zapatos (tenis, por favor no sandalias) Zapatos para la alberca (no es necesario usar zapatos en la alberca, pero si para salir de la alberca) Calcetines (1 par o más) Asistencia para incontinencia (si es necesario, ejemplo: pañales) Equipo: Silla de ruedas (traer si es necesario para movimiento diario o cansancio) Dispositivo de asistencia (traer si es necesario para movimiento general vertical o comunicación) Aparatos ortopedicos/ortesis (por favor de traer todos que se usan diario) Otras: Bloqueador solar