2016 Summer Camp Application

Transcription

1 2016 Summer Camp Application Contact Information Camper s Name: Last First Middle Address: Street City State Zip Telephone: ( ) Male: Female: Birth Date: / / County: Ethnic Background (optional): Has camper attended ITC before: Yes No Parents/Guardians Full Name: Address (if different): Street City State Zip Address: *No person shall be excluded from services because of race, religion, sexual preference, disability or national origin. T-Shirt Size: Youth S M L Adult S M L (please circle one) session Camp ALEC A 5 minute unedited video with examples of your child communicating may be requested, but is not required at this time. Primary mode of communication at home: Primary mode of communication at school: How does your child indicate YES? How does your child indicate NO? Is your child s Yes/No response: Reliable Inconsistent Approximate Language Comprehension Level: Verbal Abilities: Does your child use any gestures consistently for communication? Please list: Communications Systems: Check all that apply: Manual Communication Board Speech Generating Device Device Name Device page set (if applicable): Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 1 of 13

2 How does the child access the device? (Please explain): Direct Selection: Scanning: Switch Type and Access Site: Switch Accuracy (Estimate % Correct): Tendency to hit switch more than once: Briefly describe vocabulary organization of child s device (e.g. # of pages or levels; # of pictures or words per overlay): Is the device mounted to a wheelchair? Yes No How long has the child had the device? When learning, my child works best in: 15-minute sessions Individual sessions With 1-1 behavioral support 30-minute sessions Group sessions With hand-over-hand support Status of reading and writing skills: Knows most of the letters most of the time? Yes No Interested and engaged during book sharing? Yes No Books/subjects that are most interesting or motivating for your child: Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 2 of 13

3 How does your child use their device? Check all that apply: Independently Answers questions only One word response WIth language models With verbal prompts Preprogrammed phrases/responses Builds own phrases/sentences Spells words/uses word prediction Has access to core volcabulary Initiates social exchanges Can signal if he/she needs help, please describe Would someone unfamiliar with your child s customized pages be able to model language and help your child locate volcabulary? Please describe approximate reading level: Please describe how your child accesses books: Please describe how your child writes: Please describe approximate writing level: What does attending Literacy Camp mean to you? Please attach your child s current IEP to this application. Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 3 of 13

4 release agreement I,, hereby affirm that I am a camper and that I am of lawful age and legally competent to sign this Release Agreement or that I am the parent or legal guardian of who is a camper and that I am lawful age and legally competent to sign this Release Agreement. I give permission for me or my minor child to attend ITC and participate in all phases of the activities, including swimming, boating, and trips away from ITC. I am aware of the possible risk of injury or death to me or my child as a result of participation In the programs at ITC, and I acknowledge that by this Release Agreement neither ITC, nor its directors, instructors, agents or employees may be held liable for any injury to or death or, me or my minor child whether or not such injury or death result from the negligence of ITC or its directors, instructors, agents or employees. Wherefore, in consideration for ITC allowing me or my minor child to participate in its programs, I hereby agree to personally and fully assume all risks in connection with my or my minor child s participation in ITC programs, and I release and discharge ITC and its instructors, agents and employees from any and all claims or causes of action, whether present or future, whether known, anticipated, which may be brought by me, my minor child, my family, estate, heirs or assigns arising out of any occurrences in connect ion with my child s participation in ITC programs which may result in the injury or death of myself or my minor child, whether or not such an injury or death is caused by the negligence of ITC or is directors, instructors, agents or employees. Additionally, in case of any injury to me or my child, I give permission for ITC to secure medical and surgical treatment and provide routine, nonsurgical medical care for me or for my minor child, in my absence, while attending camp. I give permission for me or my child to be photographed or videotaped in camp activities and allow ITC/Camp ALEC to use these photos for general promotional usage. It should be understood that any print utilized will be done so in a most respectful manner, and in no way shall be used to exploit an individual. I further state that I have signed this agreement voluntarily after fully informing myself of its contents. Date Adult Camper or Parent/Legal Guardian emergency information Unless otherwise requested, the parent/legal guardian listed below will be the first person contacted in the event of an illness or injury. Parent/Guardian Name: Place of employment: Hrs reached: Work phone: Other Phone #: Parent/Guardian Name: Place of employment: Hrs reached: Work phone: Other Phone #: If parent/legal guardian cannot be reached, whom shall we contact (in order of preference)? 1) ( ) Name Relation to Camper Phone # 2) ( ) Name Relation to Camper Phone # While camper is at ITC, parents will be: At home On vacation Can be reached at: ( ) Name/Location Phone # Who will be picking camper up on outgoing day: Name Relation to Camper Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 4 of 13

5 camper information CAMPER NAME: BIRTHDATE: / / SESSION(S) MALE: FEMALE: NICKNAME, IF ANY: Check all applicable: DISABILITY Cerebral Palsy Muscular Dystrophy Spina Bifida Multiple Sclerosis Rheumatoid Arthritis Epilepsy Arthrogryposis Osteogenesis Imperf. Visual Impairment Autism/ASD Down s Syndrome Other (please explain) Congenital Anomalies/Birth Defects Explain in detail CHI (Closed head injury) Mental Impairment Mild (Cognitive Impairment) Moderate Severe Other (please explain) COMMUNICATIONS No communication difficulties Verbalizes, may be difficult to understand Non-verbal, Yes/No Responses Only Explain Explain communication board or system Additional information that would be helpful Is camper allergic to service dogs? Yes No GENERAL HEALTH INFORMATION Does camper have seizures? Yes No Frequency Please describe the seizures including length and severity Common signs/conditions of seizure Does the camper have allergies? Yes No If yes please explain agent and reaction in detail SPECIAL EQUIPMENT THAT CAMPER WILL BE BRINGING TO CAMP AMBULATION Crutches EATING Special Cup OTHER Hoyer Lift Walker Special Dish Toilet Commode Wheelchair Special Utensils Communication Board Helmet Elec. Wheelchair Plate Guard Pace Maker Scooter Other: Other: Other: BRACING AFO Hand Splint Other: Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 5 of 13

6 activities of daily living EATING Independent Needs only food cut & plate set Must be fed AMBULATION Walks Independent Needs assistance* *Describe Depends on mobility device* *Describe DRESSING & UNDRESSING Independent Need assistance with fine motor skills Total assistance PERSONAL CARE INFORMATION Check any which camper will need assistance with Showering Shaving Teeth-Brushing Personal care menstrual cycle Toileting Wears Briefs Independent Needs assistance* *Describe Special bowel treatment/program (describe) How often does camper have bowel movements: TRANSFERS Approximate Weight Independent Can bear weight for pivoting Must be lifted Precautions that should be taken if any: BEHAVIOR NEEDS Does camper have any behavior problems? If yes, please: Describe Frequency How might we best accommodate these behavior problems ADJUSTMENT TO CAMP Has attended Indian Trails Camp before If new to Indian Trails Camp, has the camper been to another camp in the past Any known fears CABIN-MATE REQUESTS Please list any requests you have for cabin mates. We will try our best! 1) 2) other Anything else that wasn t mentioned above: Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 6 of 13

7 financial form Camper Name: Age: County: 1. Complete the attached Level Determination Form and submit with application. Check appropriate level below. LEVEL 1 Minimal Dependence $762 (6-days) + * $250 Literacy Portion LEVEL 2 Moderate Dependence $1,116 (6-days) + * $250 Literacy Portion LEVEL 3 Complete Dependence $1,536 (6-days) + * $250 Literacy Portion * This portion paid for by the Alec G. Cunningham Foundation. If at any time after receipt of this form and camper application, the Camp Director and/or Health Director find the camper to require a different level of care than indicated, Indian Trails Camp reserves the right to change the level and fee accordingly. The camper and/ or family will be notified if such change occurs. 2. Based on the above Level Determination, complete the following calculations. TOTAL DUE based on tier $ $250 Literacy Fee paid for by the Alec G Cunningham foundation $ 0 - DEPOSIT* (non-refundable $100) Check # or Credit Card (complete part 3 B) BALANCE DUE $ I have a financial need and request scholarship funding (complete 4 below AND a scholarship application) 3. Complete A, B or C to indicate source of payment. If a scholarship is requested and granted, that amount will be deducted from the indicated payment option. A. PARENT/GUARDIAN OR SELF WILL PAY in full by June 15, 2016 B. CREDIT CARD PAYMENT: VISA MASTERCARD SECURITY CODE EXP / Card Number Zip Code Name as it appears on card Ph # ( ) Card billing address C. BILL ORGANIZATION: Name: Address: Ph # ( ) Fax # ( ) Attn: Amount to be paid: Send bill: before (or) after session. Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 7 of 13

8 scholarship application form The Alec G. Cunningham Foundation is a small, nonprofit organization dedicated to providing campers with disabilities a rich camp experience while also adding the literacy component to this specialized week at Indian Trails Camp. Our goal is to reduce the cost of camp. Scholarship funds are limited, and made possible by the generosity of many individuals, families and small fundraising events. The Alec G. Cunningham Board of Directors will determine applicant eligibility for scholarships and amounts awarded based on the information recorded below and available scholarship funds. MAXIMUM SCHOLARSHIP AMOUNT IS $500 BASED ON AVALIBLE FUNDS AND NEED. Camper Name: Age: Grade: Address: City: State: Zip Code: County: 1. Indicate your family circumstances by accurately completing the information below. Gross family income from all sources: < $30,000, $31-50,000, $51-70,000 $71-90,000, $91 110,000, >$ 110,000 Number of people dependent upon above income: 1, 2, 3, 4, 5, 6, > 6 2. What other potential funding sources have you investigated? church/religious organization (s), community/humanitarian organization (s), disability funding agencies, personal fundraising, extended family/friends other (explain) Contact Indian Trails Camp for fundraising ideas, or ideas can be found at: 3. Record below any extraordinary circumstances that we should take into consideration. live independently, change in level determination, unusual medical expenses, unemployed, sudden change in circumstances, other 4. Complete the calculation below to determine the requested scholarship amount. TOTAL DUE (from Financial Form): $ - AMOUNT I CAN PAY: $ - AMOUNT FROM OTHER SOURCES $ = REQUESTED SCHOLARSHIP: $ 5. Return the Scholarship Application Form with your application. I attest that the information recorded above is accurate to the best of my knowledge. Signed: Date: Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 8 of 13

9 level determination level determination Level 1 (1:3) Campers are provided one direct care counselor per three level 1 campers. Level 1 is for campers who are able to perform most of their ADL s (Activities of Daily Living) independently. Campers in this level take between 0-4 medications per day and do not have any current ongoing medical concerns. Camper is independent with eating, or requires some verbal prompts and/or with minimal physical assistance (e.g. cutting up food). Camper is independent with hygiene needs, or may require some verbal prompts to ensure completion or thoroughness. Camper is Independent with toileting, or requires minimal verbal prompts. Camper is independent with practicing coping skills and staying focused on task at hand, or requires minimal verbal prompts or redirection. Level 2 (1:2) Camper at this level are served with one direct care counselor per two campers. Level 2 Campers require some physical assistance but are independent in other areas of care. Camper in Level 2 may not exceed 8 medications to be taken daily, and may have minimal medical concerns. Camper may require minimal physical assistance with accessing food at meals, and/or requires specialized diet/nutrition (e.g. puree food). Camper may require minimal physical assistance with hygiene needs to ensure completion or thoroughness. Camper may require minimal physical assistance (e.g. wiping) with toileting. Camper may require verbal prompts or redirection with practicing coping skills and staying focused on task at hand. Camper may be dependent on a mobility device (e.g. walker, cane, etc) but is able to use this primarily independently. Level 3 (1:1) Level 3 is reserved for campers who need one-to-one assistance the majority of the time due to medical or behavioral situations. Medications may exceed 8 per day. Campers who require medical treatments such as feeding tubes and severe seizure monitoring are automatically Level 3. Camper may require full assistance with accessing food at meals. Camper may require full assistance with most or all hygiene needs. Camper may require full assistance with toileting including transferring, diapering, and wiping. Camper may require verbal prompts and redirection with practicing coping skills and staying focused on task at hand most to all of the time. Camper may be dependent on a mobility device (e.g. manual/electric wheelchair, scooter, etc) at all times, and may be independent with using it or needs assistance. Camper may be a flight-risk. If you are unsure of which level maybe most appropriate please contact Indian Trails Camp at Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 9 of 13

10 insurance form Camper Name: Camp ALEC Session * IMPORTANT: Indian Trails Camp, Inc. does not carry medical/accident insurance for campers. It is the responsibility of the camper/guardian to obtain adequate insurance coverage for any medical needs, including accidents. I understand the above: Signature parent/guardian or adult camper Is the camper covered by medical insurance? Yes No If yes, please list the camper s health insurance carrier (examples: Blue Cross, Medicare, PPOM, etc) Policy Number: Contract Number: Card Holders Name: Please attach a current copy of the card to this form. Additional information: Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 10 of 13

11 camper physical form This form MUST be completed by a licensed physician on or after 2/1/2016. This form MUST be completed in its entirety. We CANNOT accept applications for campers with incomplete medical information. Camper Name D.O.B / / Sex 1. Applicant must be diagnosed with a physical disability, developmental disability, mental illness, Downs Syndrome or Autism. 2. Applicant must be capable of social interaction and participation in camp activities. 3. Applicant must be able to communicate needs through at least a yes or no response (e.g. eye blinks, headshake, or use of communication board, etc). Primary Diagnosis/disability: Secondary Diagnosis: Medical History Asthma/Respiratory problems Diabetes type: Heart Defect Apnea Kidney Disorder Other Does the camper frequently suffer from any of the following (check all applicable)? Headaches Sore Throat Ear Infections Immunizations (check all that has been issued): Diphtheria Measles Small Pox Pertusis Polio Rubella Date of last Tetanus / / (must be within 10 years) Date of last TB test / / (must be within last 3 years-attach copy of TB card) Result: Positive Negative If positive, date of X-ray / / Does camper have known communicable diseases? Measles Hepatitis: A B C (circle one) HIV positive Chicken Pox Other: Allergies and Reaction: Seizures indicate type, length and frequency: Current Health: Age Weight BP HR RR Temperature Pulse Ox Overall health condition: Other information for health care staff, including treatments to be continued at camp, activity restrictions, medically prescribed meal plan or dietary restriction while at camp I have treated this applicant for: years months and am familiar with the camper s disabilities. In my opinion, the applicant is physically and emotionally able to participate in an adaptive camp program. The information provided on this form represents my authorization for distribution of medications as well as treatment/care. Physician s Signature Date Physician s Office Name & Phone # Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 11 of 13

12 medication record Please list ALL medications. The back of this sheet may be used if needed. Note: Camp medications are distributed at 9AM, 12N, 2-4PM, 5PM, and 9PM. Any deviations must be indicated by a physician. Only medications and dosages listed on this form will be approved on camp registration day. Any medications not listed on this form will not be administrated at camp without prior written approval of the physician. This includes ALL over the counter non prescriptions and prescriptions medications. Medications must be brought in their original bottles. If you choose to bring them set up in a med container, pill bottles must still be brought to verify prescription. **Please be sure to obtain written approval for any deviations of prescriptions written on bottle prior to camp registration. Name of Medication Dosage Prescription, as listed on bottle** Time(s) given Depakote 250mg 3 tabs by mouth twice daily 9am and 9pm Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 12 of 13

13 summer camp checklist DATE SENT FORM NEED BY 13-Page Application ASAP *Note Applications are due by May 28, After this date applications will still be considered if slots are still available. Financial Form ASAP *Note: Send with application Level of Determination ASAP *Note: Send with application Most Recent IEP ASAP *Note: Send with application Insurance Card ASAP *Note: Send with application Physical Form 3 weeks prior to camp session DROP OFF TIMES FOR CAMP ALEC IS 3:00PM - 5:00PM PICK UP TIMES FOR CAMP ALEC IS 10:00 AM -12:00 PM. You will have a chance to meet with your child s literacy Counselor at this time. This session has only 20 slots and will fill up fast. Please send your application, financial form, level of determination, IEP and copy of insurance card with your deposit as soon as possible to reserve your spot. If an agency or insurance company pays in full for your session your initial deposit will be returned to you. IF YOUR CAMPER HAS BEEN ACCEPTED TO CAMP ALEC YOUR DEPOSIT WILL NOT BE REFUNDED. NOTE: Please send all forms as soon as they are completed. Final acceptance/confirmation notices will be sent once all completed paperwork is received. We would advise you to mail us the completed application, financial form, level of determination, IEP and copy of insurance card even if you do not have the physical form completed so that your spot is reserved. Then mail in the physical form upon completion but no later than 3 weeks prior to camp session. APPLICATIONS ARE DUE MAY 28, 2016 AT WHICH TIME WE WILL OPEN UP ANY AVAILABLE SPOTS TO THOSE WAITLISTED. We will continue to accept applications after this date if spots are still available. Mail applications to: Camp ALEC C/O Gina Cunningham Cottisford Street Northville, MI Or Fax to: 1(248) For additional information please contact us at campalecinfo@gmail.com. Indian Trails Camp 2016 Camp ALEC Summer Camp Application Page 13 of 13