July 6-8, 2017 Texas 4-H Conference Center

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1 July 6-8, 2017 Texas 4-H Conference Center Thank you for your application to Mission Possible! To ensure we can adequately meet each campers needs, please complete this form and return either by mail to the Texas 4-H Conference Center, 5600 FM 3021, Brownwood, TX 76801, fax to 325/ or Applications are accepted until camp is full. Please read carefully and follow the instructions as printed. Additional information regarding your camper is requested to provide a better camping experience for your son or daughter. The information will be kept in strict confidence and will only be shared with Texas 4-H Conference Center staff and volunteers serving during Mission Possible. Your attention to detail and sharing of information will help us in providing a comfortable and pleasing experience for all involved. If you have any questions or would like to speak with someone in person, please contact Dr. Darlene Locke, at 979/ or dlocke@ag.tamu.edu Sincerely, B. Darlene Locke Extension Specialist, 4-H Youth Development 4180 State Hwy 6 College Station, TX / dlocke@ag.tamu.edu Educational programs of the Texas A&M AgriLife Extension Service are open to all people without regard to race, color, sex, religion, national origin, age, disability, genetic information or veteran status. The Texas A&M University System, U.S. Department of Agriculture, and the County Commissioners Courts of Texas Cooperating.

2 Mission Possible Medication Policy and Procedure Please read carefully Please bring your camper s medications in the original prescription labeled container. It is suggested that you only send the amount of medication needed for camp (three days, two evenings). State requirements will not allow us to keep your camper and administer the medications unless you bring the original medication containers with the correct prescription label to camp. Follow the same procedure for over-the-counter medications, vitamins, and supplements. Bring liquid medication(s) in the original container(s). If a prescription label is incorrect on a container, we will need a signed note from the doctor with the correct information. Upon arrival at camp, you will give all medications, both prescription and non-prescription, to the nurse on duty. Please provide a list, either typewritten or hand printed, of the medication and dosage, and time to be dispensed. This will be reviewed by the nurse at check-in. Example of Medication Instructions: Camper s Name: Time of Dose: Time of Dose: Ima Happy Camper 0800 Breakfast Depakote 125 mg, 2 capsules Multivitamin, 1 chewable 2100 Bedtime Depakote 125 mg, 2 capsules Frequently asked questions: 1. What if my camper has medications that are not pills, such as liquids, powders, inhalers, and creams? Bring the medication in the original labeled container. Please make sure there is enough to make it the duration of camp. 2. What if my camper s meds come in a blister pack from the pharmacy? Blister packs are a sheet of cardboard with a plastic bubble for each dose of medication and you just push the medication to get it out. Just bring the blister packs, making sure the label on the blister pack is correct. This is considered the original container. 3. What if the medication container does not have the correct dose amount or times? We realize that sometimes the amount or times change. If this happens, there are two ways to fix it. You can get the doctor to call in a new prescription and have new labels printed at the pharmacy, or get the doctor to write a note with the correct information and sign it. It must have the doctor s signature and the date on the note. We are not allowed to give medications differently than what the doctor has ordered. 4. What if my camper has meds they only take occasionally, as needed? Bring those in their original, labeled containers. This includes any over-the-counter medications. 5. What if I forget or don t have my camper s original medication bottles? Unfortunately, we will not be able to legally dispense the medication, thus YOUR CAMPER WILL NOT BE ABLE TO STAY AT CAMP. IT IS YOUR RESPONBILITY TO COMPLY WITH THE MEDICATION POLICY AND PROCEDURES. IF YOU HAVE ANY QUESTIONS, PLEASE CALL DARLENE LOCKE AT

3 Mission Possible additional camper information INSTRUCTIONS: Complete the entire form and return to the Texas 4-H Conference Center. Camper Name FIRST LAST Parent Name Phone FIRST LAST Emergency Contact: Person to be contacted in case parent or guardian cannot be reached in an emergency: Name Phone Medical Diagnosis: MEDICATIONS are being sent with minor in quantity to meet his/her needs during camp. Yes No Please read and comply with Mission Possible Medication Policy and Procedures. Additional information will be required on Health Statement GENERAL INFORMATION Please complete with as much detail as possible. Staff depend on the information to acquaint himself or herself with the camper and to ensure a positive experience for all. MEDICAL INFORMATION: (check all that apply) dehydrates easily easily constipated frequent loose bowels/stool uses inhaler diabetic uses insulin pump bi-polar medications for anxiety medications for depression seizures Type of seizure: Frequency Duration ALLERGIES: List all known allergies, including medications, food, insects, etc. Describe reaction to allergies: How do you know when camper does not feel well? Operations or Serious Injuries (list along with approximate date). Chronic or Recurring Illness:

4 BEHAVIOR MANAGEMENT: (mark an x for all that apply) is hyperactive may become homesick likes to be center of attention may use foul language prefers to work alone may become aggressive when upset may be stubborn does not like to be touched may express self physically, i.e. hugs often management strategies that work at home or school: withhold privileges time out redirection other (explain) (what works best for you) IF CAMPER HAS A BEHAVIOR PLAN, PLASE ATTACH A COPY. DAILY LIVING SKILLS Please complete with as much detail as possible. EATING: (mark an x for all that apply) no assistance needed difficulty swallowing solids needs Thick-It some assistance needed has a tongue thrust uses a straw total assistance needed needs food blended assist with cutting will provide special utensils difficulty swallowing liquids assist with drinking requires a special diet other PERSONAL CARE: (mark an x for level of assistance needed) Dressing none some assistance total assistance Bathing none some assistance total assistance Combing Hair none some assistance total assistance Brushing Teeth none some assistance total assistance Toileting none some assistance total assistance Transfering none some assistance total assistance Does camper wear dentures? Yes No Does camper wear diapers/depends? Yes No Does camper use catheters? Yes No Type of catheters: MOBILITY: (mark an x for all that apply) walks alone walks with assistance walks with crutches/walker uses manual wheelchair uses electric wheelchair other COMMUNICATION AND SENSES COMMUNICATES: (mark an x for all that apply) speaks clearly may be difficult to understand uses gestures writes uses communication board uses eyes uses sign language other

5 EYESIGHT: (mark an x for all that apply) 20/20 vision some vision blind wears glasses will bring glasses to camp will not bring glasses to camp special instructions: HEARING: (mark an x for all that apply) normal hearing some hearing deaf wears a hearing aid (left ear) wears a hearing aid (right ear) will not bring aid(s) to camp special instructions: SLEEPING/MISCELLANEOUS (mark an x for all that apply) Does camper have any special needs at night? (positioning, sleeping, toileting, equipment) (please explain) Does camper sleep through the night? Yes No Does camper require a nap during the day? Yes No Does camper have any known fears? Yes No please list SPECIAL REQUESTS: Indicate if camper wishes to be in the same cabin with a specific camper. Yes No (camper name) Indicate if camper may have privacy or space issues in dormitory. Yes No Describe Please understand that we will make every effort to accommodate these requests. CAMP ACTIVITIES (mark an x for all that apply) RESTRICTIONS WHILE AT CAMP: SWIMMING: (mark an x for all that apply) swims well needs flotation devices does not know how to swim fear of water will provide floats limited swimming skills shallow end only cannot get head wet has tubes in ears NO SWIMMING Special instructions: CHALLENGE (ROPES) COURSE: (mark an x for all that apply) The Challenge (Ropes) Course is a series of elements that range from six (6) inches above ground to three (3) feet above the ground. One element (the climbing tower) is twenty-five (25) feet above the ground. Each participant must wear safety equipment (furnished by certified instructors) and is secured by safety cables. Two counselors assist them at all times. has done this before is afraid of heights has never done needs some assistance no assistance NO ROPES ACTIVITIES Special instructions:

6 USE THIS SPACE TO TELL US ANYTHING YOU WOULD LIKE TO SHARE ABOUT YOUR CAMPER THAT WOULD HELP US TO PROVIDE A POSITIVE CAMP EXPERIENCE. Answering YES to any question does not disqualify your child, it only helps us positively manage his/her behavior. Stress triggers: Communication style and system: Social interactions: Does camper have issues with personal space : Has camper experienced any traumatic event that could affect his/her behavior while at camp? Repetitive behaviors and special interests: Does camper have any history of aggressive behavior? (hitting, biting, shoving, pulling hair): Has the camper ever reacted violently towards another individual: Behavior management techniques used: Calming activities: Motivators: Typical morning routine: Typical bedtime routine: Other:

7 CONSENT TO PARTICIPATE IN MISSION POSSIBLE This camper health & consent form is correct and complete to the best of my knowledge and the person herein described has permission to engage in all camp activities except as noted. Name of Family Physician Medical Insurance Carrier: Policy Number: Are immunizations current? yes no Date of last Tetanus immunization: Signature of responsible parent/guardian: Printed name date Signature PHYSICIANS AUTHORIZATION I have examined the person herein described and reviewed his/her health history. It is my opinion he/she is able to engage in all camp activities, except as stated. signature of examining physician printed name phone number, including area code mailing address date of exam Please note, in addition to completing this application, Mission Possible participants must also complete the Health Statement. There may be duplication of information requested in some areas. But, it is in the best interest of the youth participant.