Kamp for Kids at Camp Togowauk

Transcription

1 Behavioral Health Network Kamp for Kids at Camp Togowauk Summer 2018 Information and Application AN INTRODUCTION TO KAMP FOR KIDS AT CAMP TOGOWAUK We're eagerly looking forward to another year of Kamp for Kids. Kamp operates Monday - Friday, 9:00 a.m. until 2:00 p.m. We provide a fun summer camp experience which includes: Spray Park, expressive arts, outdoor education, arts & crafts, noncompetitive sports and many other exciting activities! We are located at 754 Russell Road, Westfield, MA. If you are planning to have your child/children join us this summer for any of the sessions, please fill out the accompanying forms, so that we can prepare everything for you. If necessary, please include an additional page with information which will not fit on the form. If you have any questions, feel free to call us at (413) Hope to see you at Kamp! WHO IS ELIGIBLE FOR SUMMER CAMP? Children and young adults ages 3-22, both with and without disabilities. WHAT IS THE COST? A non-refundable registration fee must be sent in with the application. Our graduated non-refundable registration fee scale per family is as follows: $25.00 first child, $15.00 second child, and $10.00 third child. No additional fee is charged after the third child. Please note that no application will be processed without this fee. If an agency or school system will be paying for a camper's session(s) and/or registration fee, please be sure to fill in the billing information on the application. The agency or school system will then be required to sign and return a Billing Authorization Form before any camper is registered. The cost for a two-week session is $ There is some funding available through the Department of Developmental Services (DDS). Also, there are a limited number of full and partial Kamperships available through private grants. If you are interested in applying for financial aid, please include income verification with the completed application. This may include copies of pay stubs, Social Security statement, DTA TANF award letter, etc. Camperships are based on income as determined by Federal HUD guidelines and grant criteria. HOW DO I APPLY? Please keep in mind that camper registration is based on a first come / first served basis and space is limited. 1) Applications are preferred by June 4, 2018 for session One and July 9, 2018 for sessions 2 and 3. We will accept applications until the session is full then potential kampers will be put on a waiting list. Please note that there is no guarantee of acceptance. Complete applications are processed on a first come/ first served basis. It is important to note that sessions fill up very quickly. By applying early, applicants are more likely to receive a slot and their session of choice. WE WILL NOT ACCEPT FAXED APPLICATIONS. 2) Upon acceptance, notification will be sent to you, which will include the session(s) a camper has been assigned and items required at camp. For campers receiving transportation, a phone call from the bus company (VanPool Transportation) will be made prior to the first pick up of the session. 3) Incomplete applications will delay your acceptance to a session. All paperwork should be mailed to: Kamp for Kids 754 Russell Rd, Westfield, MA All checks may be made payable to Behavioral Health Network. If you have any questions or concerns, please call the main office of Kamp for Kids at (413) We suggest you make a copy of this completed application and all documentation returned with it for your own records.

2 Date rec'd: Complete: Yes No Amt. fee rec'd: Returned: Yes No Check #: Paid by: For Office Use Only RECENT PHOTO OF CAMPER IS REQUIRED PLEASE ATTACH KAMP FOR KIDS AT CAMP TOGOWAUK APPLICATION FAXED APPLICATIONS WILL NOT BE ACCEPTED. MUST BE FULLY COMPLETE BEFORE CAMPER CAN BE CONFIRMED. Mail to: Kamp for Kids 754 Russell Rd, Westfield., MA (413) Applications are accepted until slots are filled. By applying early, applicants are more likely to receive their first choice of session. Applications need to be sent in as soon as possible. Please note that applications are not processed without the registration fee. PLEASE PRINT OR TYPE IDENTIFYING CAMPER INFORMATION Last Name First Name Middle Name Prefers to be called Birth Date Age at Camp Gender Home address: Street City State Zip code Ethnic Group: Caucasian Hispanic African American Asian Native American (Optional) Other PARENT OR GUARDIAN INFORMATION Name Address (if different from camper) City State Zip code Home Phone: Work Phone: Cell Phone: EMERGENCY CONTACT INFORMATION (Person to contact if Parent/Guardian is unavailable) Emergency Contact Name Relation to Camper Emergency Contact Name Relation to Camper Phone Number Authorized to pick up camper?* Yes No Phone Number Authorized to pick up camper?* Yes No *Parents, guardians, and emergency contacts must present photo ID when picking up a camper. Campers will not be released to unauthorized parties. I hereby certify that all information given is true and complete. Name of Parent or Guardian (please print): Parent or Guardian Signature:

3 2018 KAMP FOR KIDS AT CAMP TOGOWAUK APPLICATION CAMPER HISTORY FORM TYPE OF DISABILITY: (I.E. Autism, ADHD, Developmental Delay, Cerebral Palsy) PLEASE CHECK APPROPRIATE AREA(S) OF NEED Trunk Neck Legs Balance Coordination Eyes Hands Non-Speaking Understanding Social Adjustment Communication Other (please list) If non-verbal how does child communicate? Needs support for head balance: Needs support in sitting: Needs assistance in eating and/or drinking Needs support in walking Needs assistance dressing and/or undressing Needs assistance toileting Needs assistance with braces Needs assistance in mobility (stairs, slopes) Has toileting accidents Has difficulties following directions Wanders away from groups Needs 1 to 1 assistance or supervision Other If the individual has seizures, please provide details: Always Sometimes Never Length: Frequency Type Please give specifics on how you handle the seizure(s): Does the individual use any of the following special equipment? Wheelchair Electric Artificial limb Respiratory equipment Wheelchair Hearing Aid Ileostomy equipment Walker Orthopedic corrective device Leg braces Crutches Communication device Other Please comment on any special equipment care or suggestions: Please indicate exercise or other routine that you wish the individual to maintain: Does the individual have an individualized education plan? Yes (9 month) Yes (12 month) No *Must enclose copy of plan with application.* What school program does participant attend? Contact person for additional information: Address: Title: Telephone:

4 2018 KAMP FOR KIDS AT CAMP TOGOWAUK APPLICATION SESSION INFORMATION CAMPER NAME: PLEASE CHECK SESSION(S) DESIRED: Only mark the session(s) that you would like the camper to attend. Mark your first and second choices. If accepted, the camper is expected to attend every day of the session. Please review dates carefully. Kamp session dates have changed. FIRST SESSION- JULY 9 - JULY 20 $850.00/two week session SECOND SESSION- JULY 23 AUGUST 3 $850.00/two week session THIRD SESSION- AUGUST 6 - AUGUST 17 $850.00/two week session ****Please note that if the Kamper requires 1 to 1 assistance (provided by the school or family), the aide MUST provide all required documentation and be present each day or the Kamper will be sent home for the day. Please initial **** PAYMENT INFORMATION MUST BE FULLY COMPLETED BEFORE CAMPER CAN BE CONFIRMED. Please check payment arrangement: Once accepted and registration is confirmed, payment is expected regardless of attendance. I will be paying the Kamp fee directly. (We will bill you.) Initial here Payment in full is due before starting Kamp. My child is served by DDS. The camp fee will be paid by the following agency / school system (Please fill out completely): Name of Agency or School System: Contact Person or DDS Coordinator: Phone Number: Address: I would like to be considered for financial assistance. Kamp for Kids may offer a full or partial Kampership to eligible applicants. Please note that financial assistance can only be provided for one session unless spots remain open. If applying for financial assistance, you must include income verification : - 2 consecutive pay stubs, Most recent tax return, SNAP or TANF award letter, Unemployment Compensation, Child Support, Social Security, SSI, Workers Compensation, Veterans Benefits, Pensions or Rental, any other type of income. Please include all that apply to your family. Please note that if the camper receives financial assistance to attend camp, we must release the required information to the funding source. FINANCIAL INFORMATION FORM Everyone MUST fill out this information Your responses will have NO impact on the camper's application. This information is requested by the foundations which give us scholarship money and grants for equipment for the camp. To be eligible for these funds, we must document that Kamp for Kids at Camp Togowauk serves the entire community. This information helps us show that the campers served represent the entire range of socioeconomic possibilities in the region. Please be assured that per federal HIPAA regulations, the privacy and confidentiality of your responses are guaranteed. Name of Camper: Parent or Guardian Name: Family Size: Adults Children Head of Household : Male Female Number of family members with a disability Source of Income (please check all that apply): Employment TANF Unemployment Other Family Income (please check one): Under $12,000 $25,001 - $30,000 $45,001 - $50,000 $62,501 - $65,000 $12,001 - $15,000 $30,001 - $35,000 $50,001 - $55,000 $65,001 - $67,500 $15,001 - $20,000 $35,001 - $40,000 $55,001 - $60,000 $67,501 - $70,000 $20,001 - $25,000 $40,001 - $45,000 $60,001 - $62,500 over $70,000

5 Camper's Name: 2018 KAMP FOR KIDS AT CAMP TOGOWAUK PHYSICIAN HEALTH FORM MUST BE FULLY COMPLETED BEFORE CAMPER CAN BE CONFIRMED. Mail to: Kamp for Kids 754 Russell Rd, Westfield., MA (413) Date of Birth: I examined the above camp participant on * Cannot accept form without this date. * BP Weight Height In my opinion, the above applicant IS IS NOT able to participate in a day camp program. The applicant is under the care of a physician for the following conditions: Current treatment at the time of this report includes: RECOMMENDATIONS AND RESTRICTIONS AT CAMP (Please be specific) Treatment procedures to be continued at camp: Medications to be administered at camp (Name, Dosage, Frequency): Any medically prescribed meal plan or dietary restrictions: Known allergies: DESCRIPTION OF ANY LIMITATION ON CAMP ACTIVITIES: ADDITIONAL INFORMATION FOR HEALTH CARE STAFF AT THE CAMP: TB Mantoux Test: Date of last Test: Result: Positive Negative Measles: Yes No Chicken Pox: Yes No German measles: Yes No Mumps: Yes No Hepatitis A: Yes No Hepatitis B: Yes No Hepatitis C: Yes No TB Mantoux Test: Date of last Test: Result: Positive Negative PLEASE GIVE ALL DATES OF IMMUNIZATION FOR: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr VACCINE DTP TD (tetanus/diphtheria) Tetanus* Polio MMR Or Measles* Or Mumps* Or Rubella* Haemophilus influenza B Hepatitis B Varicella (chicken pox) BCG Signature of Licensed Medical Personnel: Printed: Title: Address: Phone:

6 2018 KAMP FOR KIDS AT CAMP TOGOWAUK APPLICATION AUTHORIZATION / WAIVER FORM As a non-profit agency, the following consent agreements are necessary. We must have original signatures. Thank you. STANDARD ADMISSION WAIVER I hereby affirm that I am the parent or legal guardian of and I hereby release Behavioral Health Network of legal responsibility in case of accident, which is coincidental to activities at and transportation to program site assuming that proper supervision is present. I further understand that Behavioral Health Network will not be responsible for any valuables, money, or lost articles of clothing or belongings left in the possession of this camper while he/she is at Kamp for Kids at Camp Togowauk. Articles left behind will be shipped to the camper's home address at my (parent or guardian) expense. Signed (parent or guardian): VOLUNTARY PUBLICITY RELEASE I hereby affirm that I am the parent or legal guardian of and understand that Behavioral Health Network needs to publicize its programs and events to the general public and charitable donors through media coverage, brochures, newsletters and annual reports. By signing this publicity release, I thus voluntarily give my permission for Behavioral Health Network, its agents, or media representatives covering events or programs offered by Behavioral Health Network to take and use the image and/or recorded voice of the person named below engaged in agency activities and events. I give permission for identifiable images and recordings of to be published in (please check): Photographs for print media: Yes No Agency newsletter: Yes No Videos / television footage: Yes No Fund-raising materials: Yes No Agency brochure Yes No Agency web page: Yes No Signed (parent or guardian): Mandated Reporter Policy The staff, counselors, and volunteers of Kamp for Kids are Mandated Reporters and are required by law to adhere to Commonwealth of Massachusetts General Law Chapter 119 section 51-a. This states that any reasonable suspicion of child abuse or abuse of a person with a disability MUST be reported. To protect the safety of the child/individual and authenticity of a home/ environment, it is our policy to report the situation directly to the MA Department of Children and Families or Disabled Persons Protection Commission. More information about Mandated Reporting and MAGL a can be found at:

7 2018 Kamp for Kids at Camp Togowauk Application Supervision Ratio Information Kampers Name Diagnosis Kamper supervision needed: 1 Kamper : 1 Staff 2 Kampers :1 Staff 3 Kampers :1 Staff (our usual ratio) Please explain (in detail if possible) why Kamper requires 1:1 or 2:1 supervision. What types of challenges / behaviors can be expected and any important information that will help us to serve the Kamper. Name and contact information should Kamp for KidsTM staff have questions regarding the above information: There number of 1:1 placements is limited to 4 campers per session. They are awarded on a first come first served basis. Due to high demand, campers requiring Kamp for Kids to provide 1:1 staffing will only be accepted to one session. Please note that 1:1 staff provided by family, agency, or school system MUST fill out all Kamp for Kids/Behavioral Health Network paperwork required by the State of Massachusetts, City of Westfield, and other camp Accreditation Agencies PRIOR to being on the Campsite. If this requirement is unfulfilled, the Kamper may be sent home until paperwork is completed.

8 2018 KAMP FOR KIDS AT CAMP TOGOWAUK TRANSPORTATION Please read the following section regarding bus transportation for campers. We have tried to include as much information as possible to allow parents and guardians to make an informed decision regarding a request for transportation. If after reading the section below, you still have questions, please call the main office at (413) CAMPER BUS STOPS Any camper may be assigned a bus stop for pick up and drop off. The specific bus stop locations listed below are a reference for individuals residing in areas outside of the bus transportation limits. These locations are subject to change. 1. Campers residing in the Palmer/Ware area will be picked up and dropped off at the Big Y in Palmer (off the turnpike.) 2. Campers residing in the Huntington/Chester area will be picked up and dropped off at the Littleville Elementary School. 3. Campers residing beyond Southwick will be picked up and dropped off at the Big Y in Southwick. 4. Campers residing in the Northampton area will be picked up and dropped off at the Clarion Hotel on Rte. 5. CAMPERS REQUIRING WHEELCHAIRS OR MOBILITY AIDS Bus transportation can only be provided to 2 campers requiring wheelchairs or large mobility aids per session. BUS TIMES & LOCATION In order to prepare bus routes in a timely manner and provide parents and guardians enough notice regarding bus pick up times, we will have a deadline for any transportation changes. Two weeks before each session the transportation list will be locked in and no changes will be made to it. Bus pick up and drop off times may be different from session to session. This is due to the bus route changes and the number of campers on the buses at any given session. Campers MUST be picked up and dropped off at the same location. CAMPER SAFETY A parent or guardian MUST be present at the designated pick up and drop off site at the time of bus arrival. No camper will be released without a parent or guardian being present. If at the time of drop off the parent or guardian is not present to collect the camper, they will be returned to the camp grounds and the parent or guardian will be responsible for the camper s transportation home. If your camper will not be attending a day of camp due to unforeseen circumstances, please notify both Kamp for Kids at (413) and Van Pool Transportation at (413) Does the camper need transportation? Please write in Yes or No Parent or Guardian signature: Please provide detailed information on any special circumstances or requirements regarding transportation: (Wheelchair van, monitor, seating location, equipment such as carseat or special buckle, behavioral or medical needs,etc.)