Easter Seals Iowa Resident Camp 2015 Checklist

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Jeffery Lee
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1 Resident Camp 2015 Checklist As you complete the application, please check off the items from this list: 2015 Application Health History Form + immunization records Easter Seals Physical Form (valid for 2 years) All Release Forms (Notice of Privacy Practices, Waiver of Liability, Photo Consent Form) Physical signatures on the required pages (we do not accept electronic signatures) Financial Information Form Resident Camp Registration Form Current Individual Care Plan/Consumer Comprehensive Service Plan and Release of Information (waiver clients only - please contact your case manager) Notice of Decision or $50 non-refundable deposit We require all items on this list to be submitted in order to begin the registration process. Please send them to our Program and Support Specialist, Kate Simpson, by the following methods: ksimpson@eastersealsia.org Fax: Mail or Drop Off: Attn: Kate Des Moines, Ia Once we have registered you for camp, you will receive a letter via mail confirming the week(s) you are registered for. Please contact Kate at or ksimpson@eastersealsia.org if you have any questions.

2 IMPORTANT! If you are PRIVATELY PAYING: - A non-refundable $50 deposit is required to register a camper. The camper cannot be registered until we receive this and we do not reserve or hold spots. The $50 will be applied to the first camp session. Please send the deposit with the application to our program and support specialist, Kate Simpson, at: Attn: Kate Simpson Des Moines, IA Full payment is due three weeks before the client attends his/her camp session. Failure to pay in advance may result in a loss of registration for that session. If the remaining balance is sent separately from the deposit and application, please send it to our Accounting Department at: Attn: Accounting Des Moines, IA The entire amount is required to be paid even if the camper will not attend the entire camp. - If the camper can no longer attend the registered camp, you must contact Kate Simpson at to cancel the session. You must cancel prior to the camp session. If you fail to cancel the session, you will be personally billed for the full amount of your camp session, regardless of original payment source. How to Apply for a Campship: receives funding from a variety of sources, including private donations, government agencies, and fee-for-service. To make our services accessible to as many people as possible, Easter Seals Iowa also relies on contributions. Public contributions help cover the difference between actual program costs and for those who are unable to pay for all or part of the service. Each camper is supported by donors who participate in the Annual Fund Campaign. The Annual Fund raises donated funds for these financial gaps. Campships are scholarships that are gifts from the Pony Express Riders of Iowa, the Annual Campaign, foundations, organizations, and individuals. - To apply, please fill out the Campship request section on the 2015 Financial Information page. - If applying for a Campship, we still require the non-refundable $50 deposit. Deposits are not covered under a Campship. Please send the deposit with your application. - If awarded a Campship, you will receive a statement reflecting that it has been applied to your balance due. - Clients are eligible to receive one Campship per season, not to exceed $550. Residents of group homes, nursing homes, and other facilities are eligible for a maximum Campship of $ There are limited Campships and we reward them on a first come, first serve basis. If you are interested in receiving one, we strongly encourage you to turn in all the required documents for camp as soon as possible.

3 IMPORTANT! If you are using WAIVER FUNDING: - Contact your case manager before sending in the application. Please discuss with them how many camps you are interested in, what type(s), and what dates the camps occur on. - Please send the NOD with the application to our program and support specialist, Kate Simpson, at ksimpson@eastersealsia.org or: Attn: Kate Simpson Des Moines, IA Please also have the case manager send the client s Individual Care Plan/Consumer Comprehensive Service Plan (ICP/CCSP) with the application and the NOD. This document is also required for registration. - A camper cannot be registered without a correct NOD and we cannot register outside of what the NOD authorizes. We also do not reserve or hold spots. - The entire unit amount per camp is required to be authorized on the NOD, even if the camper will not attend the entire camp. - Below are our waiver rates: Supported Day Camp: T2037 Respite Non CMH: T2036 $1.11/unit $3.16/unit 180 units a week 184 units per weekend (220 units per week for extended hours) or Respite CMH: T2036 Resident Camp: T2036 $3.34/unit $1.24/unit 184 units per weekend 484 units per week PLEASE NOTE: - The CMH waiver (Children s Mental Health Waiver) can only be used on our weekend respite camps. - All other waivers (such as the Intellectual Disabilities Waiver, the Ill and Handicapped Waiver, and the Brain Injury Waiver) are eligible for both weekend respite camps and our summer resident and supported day camps.

4 Camp Sunnyside -Financial Form- *this form is required for summer camp registration* Client Name: Birthdate: Party Responsible for Payment: Billing Address: City, State & Zip: Phone: Address for Billing: Case Manager Name: Agency: Case Manager Address: City, State & Zip: Phone: Case Manager I prefer electronic billing statements PRIVATE PAY Method of Payment: Check (make payable to ) Amount Enclosed: $ Credit Card Visa MasterCard Discover Amount Authorized: $ Card Number: Expiration Date: _ Name on Card: Signature: $50 deposit required WAIVER FUNDING Medicaid ID: Notice of Decision and CCSP required (please contact your case manager) If you are paying with waiver and a private payment, please attach notes with details. REQUESTING CAMPSHIP (not guaranteed private pay only) Amount Requested: $ Annual Income: $ $50 deposit required Please note: The non-refundable $50 deposit must be sent with application if you are privately paying. It will be applied to the first camp session. Full payment is due THREE WEEKS before the client attends his/her camp session. Failure to pay in advance may result in a loss of registration for that session.

5 Camp Sunnyside - SUMMER RESIDENT CAMP - Registration 2015 Private Pay Cost: $600 per week Waiver Rate: $1.24 per unit, 484 units per week Client Name: _ Medicaid or Social Security Number: Today s Date: Date of Birth: Guardian Name: Guardian Home Number: _ Guardian Guardian Cell Number: _ Check in is Sunday 2-4pm. Check out is Friday 2-3pm. Camp registration closes the Wednesday before the desired camp. Client Age: _ *Please mark all sessions you would like to attend* Week 1: June 7 - June 12 Ages 4-17 C1 Camp Explore Ages 4-17 S1 Rainbow Connection Week 2: June 14 - June 19 Ages 18 and Up C2 Rock N Roll Daze Week 3: June 21 - June 26 Ages 35 and Up C3 Western Week Ages 18 and Up S3 Extreme Nature 1 Week 4: June 28 - July 3 Ages 18 and Up C4 Party in the USA Week 5: July 5 - July 10 Ages 4-17 C5 Jurassic Camp Week 6: July 12 - July 17 Ages 18 and Up C6 Amazing Race Ages 18 and Up S6 Extreme Nature 2 Week 7: July 19 - July 24 Ages 4-17 C7 Splash Off! Week 8: July 26 - July 31 Ages 16 and Up C8 Fun and Fitness Ages S8 Career Camp Please list any alternative sessions you can attend in case your first choices are full

6 Summer Camp Theme Descriptions- Camp Explore - Camp Explore is being offered to all persons in Iowa with visual impairments. is collaborating with Iowa Braille School to make this a special session designed for persons with visual impairments, but anyone is welcome to join in the fun. This is a youth session. Rainbow Connection - This camp is geared towards youth campers who are on the Autism Spectrum. We will be utilizing plenty of sensory items on top of our usual summer camp traditions, such as horseback riding, swimming, lake activities, rock climbing, and arts and crafts. While this is geared towards campers on the spectrum, anyone age 4-17 is welcome. Rock N Roll Daze - If you like to rock and roll, this camp is for you! With music blaring all week long on the patio and a live performance by a cover band, this week totally ROCKS! We also encourage our campers creativity by making music and instruments of our own. Extreme Nature 1&2 - As you can see, Extreme Nature is offered 2 times this summer, because of its EXTREME popularity. Campers get to sleep in tents, cook food over an open fire, and hike through the woods. This camp is suitable for campers who can sleep on the ground and maintain a ratio of 1:7. Camp Sunnyside reserves the right to adjust the group if we feel health and/or safety is compromised. Western Week - Yeehaw! It s back again for another time around the barrel! Enjoy a rodeo, horseback riding, and lots of Country Western Music during this honky-tonk week. We will also turn camp into the Wild West with demonstrations from the Pony Express Riders of Iowa. Costumes and Western wear are encouraged! Party in the USA - This eventful week is all about festivities and having fun! Each day we will celebrate a different holiday by having a party. Campers will get to experience Halloween, a winter wonderland, Valentine s Day, and of course, Independence Day all in one week! Bring your party hats! Jurassic Camp - This prehistoric session will be full of dinosaur searching fun! Throughout the week, campers will explore high and low for fossils and animal tracks, in addition to creating some of our own. Join us in scavenger hunts on our very own nature trail and learn about all of the great nature Camp Sunnyside has to offer. Amazing Race - Travel around the world without leaving Camp Sunnyside! This adventurous camp will be full of cuisine and activities from around the world. Campers will be able to sample activities and food from China, Mexico, Italy and more during this week of international fun. Splash Off! - Be sure to bring your swimsuit to this wet and wild week! We will have pool parties and boat parties on Lake Cheerio, as well as our slip and slide. Don t forget about our water fights as well! Fun and Fitness - This camp week will be full of high energy activities that EVERYONE can enjoy. We will have yoga and water aerobics, as well as daily hikes around Camp Sunnyside. We will also offer exercise classes throughout the week and be offering new activities that will surely appeal to all campers! Career Camp - Career camp is for campers interested in gaining employment skills. Each day campers will learn a variety of employment skills, do mock interviews, fill out a resume, and end the week shadowing a Camp Sunnyside staff member. Campers must be able to maintain a 1:8 staff to camper ratio and truly be interested in learning about employment. Easter Seals reserves the right to determine the camper s appropriateness for this session.

Sincerely, Bill Selig/ camp Director

Sincerely, Bill Selig/ camp Director Dear Parents and Campers, Thank you for your interest in our wonderful Summer Day Camp! We are currently in the process of planning the most exhilarating and exciting program for all of our summer campers.