We thank you for your interest in Easterseals camp. Should you have any questions, please contact me at or

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1 2017 Dear Parents and Campers, Easterseals camp will be held August 6th through August 12th at YMCA Camp Oakes in the San Bernardino Mountains. Our theme will explore science fiction and be called "Sci-Fi Camp - The Final Frontier!" You are automatically ACCEPTED to camp if you complete and return the b elow documents by April 30, If the below items are NOT returned before April 30th, you are not automatically guaranteed a spot and we will notify you as we process applications whether we have space to accept you or not. The documents to be completed and returned by April 30 th for a guaranteed spot are: Camp Application Financial Statement (with payment or a campership request) Transportation Form The Medical Form must be completed and returned by July 15, Please complete the medication section of the 2 page Medical Form and have the doctor confirm those medications or update the list when you have your doctor's appointment. 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 $775. The actual cost per camper is $1,246 but Easterseals subsidizes $471 per camper by raising donations. If you are able to pay more than $775, we appreciate you doing so. If you have difficulty paying $775, we encourage you to solicit donations and some partial camperships are available. Regional Center will not cover the cost of Camp. We thank you for your interest in Easterseals camp. Should you have any questions, please contact me at amanda.showalter@essc.org or Sincerely, Amanda Showalter Camp Director 401 S. Ivy Street, Escondido, CA (P) (F)

2 NEW THIS YEAR All campers who take medications are required to bring them in tamper proof, single dosage packs (also known as Blister, or Bubble Packs ). This includes all prescribed vitamins and supplements. Prescription medication that is taken as needed, or PRN, is the only medication that can be brought to camp in the original labeled container. How do I do this? Ask your regular pharmacy to package one week s medication for you to bring to camp. OR Ron s Pharmacy has agreed to provide this service. Have your healthcare provider write a prescription for a one week s supply, and send that along with your insurance information to: Ron s Pharmacy Attn: Easterseals Barnes Canyon Road; San Diego, Ca Contact: Robert Rivera Phone Ext.1; Fax (Attention Robert) Robert.Rivera@Ronspharmacyservices.com Ron s Pharmacy will package these for you & provide them to the Camp Nurse. If you re unfamiliar with blister packs, this is what they look like:

3 Easterseals Southern California 401 S. Ivy Street Escondido, CA RESIDENT CAMP APPLICATION Sunday, August 6th thru Saturday, August 12th 2017 (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 Birthdate 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 8

4 Is there any special assistance needed with eating or dressing? If so, please describe: Is there any special assistance needed with toileting? If so, please describe bowel regimen (pattern/frequency/max # of days w/o B.M.; is constipation common?) Have there been any changes to health or general well-being in the past year? If so, please list: If there are any physical conditions, past operations or injuries which should restrict camp activity, please specify: If the camper is in school, works or participates in group activities, please provide details: Does the camper require special night care? Yes No If yes, please specify: Does the camper sleep through the night? Yes No If no, please specify: Does the camper exhibit self-abusive behavior or dangerous tendencies that could result in harm to him/herself or others? Yes No If yes, please specify: Is there anything else that you would like us to know? Is camper taking medication? Yes No If yes, please list all medications (INCLUDING vitamins, supplements, etc.). Please provide a comprehensive list. Breakfast Lunch Dinner Bedtime Drug Name strength/ concentration 2 of 8

5 Media Consent I give my permission for Easterseals and anyone connected to Easterseals to use any descriptions, stories, pictures, photographs, recordings of the person named above or things he or she says or does. Easterseals 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 Easterseals all rights to these materials. All of these materials made by Easterseals are owned by Easterseals 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 medications per the doctor s orders 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 Easterseals 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 Easterseals 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 Easterseals, 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 Easterseals nor the YMCA of Greater Long Beach/Camp Oakes can accept responsibility for camper s personal property. Some of the items prohibited at camp are: Cell Phones, CD players, Ipod, and Gaming Systems 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. 3 of 8

6 EASTERSEALS SOUTHERN CALIFORNIA 401 S. Ivy Street Escondido, CA FINANCIAL STATEMENT The cost of sending a camper to Camp Oakes is $1,246. Easterseals subsidizes every camper and the amount you are responsible for paying is $775. If you are unable to pay the full $775, campership funds are available, on a limited basis, for those who qualify based on income guidelines. All campers are encouraged to assist Easterseals and our volunteers 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 $775. Payment is enclosed. I will pay the full camp fee of $775 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 Easterseals. 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 Easterseals 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 $450 is required for all campers receiving campership funding. Please send your written request for a campership with the other forms to Easterseals via: Scan/ to Amanda.showalter@essc.org (preferred method) Fax to Mail to: Easterseals Southern California, 401 S. Ivy St, Escondido, CA of 8

7 EASTERSEALS SOUTHERN CALIFORNIA 401 S. Ivy Street Escondido, CA Amanda Cell TRANSPORTATION Easterseals can only provide limited bus transportation to those returning campers who have no other means of transportation. The family needs to provide transportation to and from camp if at all possible. The fee for bus transportation is: $80.00 round trip or $40.00 one way. Fee must be paid by July 1, For campers providing their own transportation: Drop off at camp is at 10:00 am on Sunday, August 6th. Lunch will be provided. Please pick up from camp on Saturday, August 12th between 9:00 a.m. and 9:30 a.m. For those campers taking the bus: Campers needing transportation must meet at Easterseals Riverside office by 11:30 a.m. on Sunday, August 6th. More information with regards to the Riverside office location will follow in the coming months. Departure from camp is at 10:00 a.m. on Saturday, August 12th. The approximate arrival time back at the Easterseals Riverside Office is 12:00 p.m. Breakfast on Saturday is the last meal served at camp. Please complete: I will provide transportation for the camper I will need transportation provided by Easterseals August 6, 2017 August 12, 2017 If you need transportation provided by Easterseals, answer the next questions. Does camper use a wheelchair? Yes No If yes, can camper transfer? Yes No If yes, can the wheelchair break down? Yes No If yes, is it electric or manual? Elec Man 5 of 8

8 EASTERSEALS/YMCA CAMP OAKES Camper Medical Form 2017 This form must be reviewed and signed by a physician. Return the form to Easterseals by July 15, Scan/ to Amanda.showalter@essc.org (preferred method) Fax to Mail to: Easterseals 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 6 of 8

9 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 S 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 Easterseals/YMCA Camp Oakes Physician Signature: Date: Physician s Name (Please Print): Office Phone: Emergency Phone: Address, City, State, Zip: 7 of 8

10 Final Check List Please be sure to submit the following forms: 1. Resident Camp Application (pages 1-5) 2. Medical Form (pages 6 & 7) 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 Easterseals by July 15, TOTAL 5 pages (without Medical Form) TOTAL 7 pages (with Medical Form) Please submit the forms by one of the following methods: Scan/ to Amanda.showalter@essc.org (preferred) Fax to Mail to: Easterseals, 401 S. Ivy Street, Escondido, CA For questions about camp, contact Amanda Showalter at Easterseals at (951) or amanda.showalter@essc.org. Please note, applications that are not complete will be returned 8 of 8