Gay Bruner, Director of Camp and Respite

Transcription

1 Easter Seals Tennessee Camp 3011 Armory Drive, Suite 100 Nashville, TN ext fax Dear camper: Thank you for your interest in our 2014 Respite/Summer Camp season. Before you begin to fill out your application, please take time to read the important information listed below. Two important NEW policy changes for 2014: Smoking and the use of any tobacco products on the Camp Widjiwagan are strictly prohibited. Cell phones, laptop computers and tablets will not be permitted. Applying to Respite/Camp: The enclosed application packet must be completed in order to be processed. Application Fee: A $ application fee is required per Respite/Camp. Applications sent without the $ fee will not be processed. The application fee is non-refundable once the camper is accepted for the respite or camp. All respite balances are due two weeks before the respite and camp balances are due 30 days in advance. Eligibility: Easter Seals Tennessee Camp believes that all adults with disabilities should have the opportunity to participate in traditional camp activities. Our knowledgeable staff and accessible camp facility can accommodate campers with a wide range of special needs. In efforts to maximize the experience of all campers there are: however, certain eligibility requirements for attending Easter Seals Tennessee Camp: Adults with disabilities (ages 17 and older) Ability to live in a group setting with other campers Camper must have the ability to control harmful behaviors to self or others Camper must be able to sleep, or sit quietly, for a reasonable amount of time throughout the night Camper must not be considered medically fragile Camper must observe the drug free and substance abuse policies of Easter Seals and Camp Widjiwagan Camper must be able to function with an average staffing ratio of 1 to 4 or must sign up for a 1 on 1 counselor additional $100 (weekend respite) and $200 (camp) Camper must surrender all medication(s) to the nurse at check in. All medications (prescription and non prescription) will be administered by the camp nurse Campers requiring medication must be able to take their medication. Any special foods etc. needed to take medications must be sent to camp with the camper Camper must provide sufficient quantities of personal care items (protective garments, wipes, bed protectors, etc.) to last throughout the Respite. Medical Form: The medical form does not have to be sent in with the camper application. The completed medical form however, must be received in the Easter Seals Tennessee Camp office 14 days prior to the first day of the respite the camper will be attending. If, upon receipt of the medical form, we find we are unable to meet the camper s medical needs, we will contact you as soon as possible. Gay Bruner, Director of Camp and Respite

2 APPLYING TO EASTER SEALS TENNESSEE CAMP Step 1: Complete all forms and information Application processing will not begin until all required application materials are completely filed out and returned to Easter Seals Tennessee Camp. The medical form is due at the latest 14 days prior to the Respite starting date. The application is made up of several sections. Please review and check the boxes below to make sure you have completed all the required sections. Deposit $ per Respite/Camp Camp Application Form - all areas must be completed Copy of Camper s Insurance Card (front and back) Recent Camper Photo Medical Form (due at least 14 days prior to the Respite/Camp starting date) Step 2: Return application packet After all required sections have been completed, please mail packet to: Easter Seals Tennessee Camp 3011 Armory Drive, Suite 100 Nashville, TN If you have questions regarding the application or the application process, please call Gay Bruner, Director of Camp and Respite at (615) , ext. 13. It is our pleasure to offer an excellent camping and respite experience to each and every camper.

3 2014 Easter Seals Tennessee Camp Application Administrative Office (where to return applications and who to contact for questions) 3011 Armory Drive, Suite Nashville, TN , ext 13 Fax (615) camp@eastersealstn.com ALL FORMS MUST BE COMPLETELY FILLED OUT. PLEASE PRINT Respite/Camp Application Camper Information Full Name Nickname Birth date / / Gender Female Male Ethnicity Phone # Cell # Street Address City State Zip County camp updates to Do you have a family member in the military? Yes No Relation to camper Branch Do you have a disability? Yes No If so, check all that apply Asperger s Syndrome Heart, Circulatory, Respiratory Defect Asthma Intellectual Disabilities Attention Deficit Disorder /ADHD Mild Moderate Severe/Profound Autism Learning Disability Behavior Disorder Muscular Dystrophy Bleeding/Clotting Disorder Psychosis Cerebral Palsy Speech-Language/Voice Dysfunction Cystic Fibrosis Spina Bifida Diabetes Spinal Cord Injury Developmental Disorder Quadriplegic Paraplegic Other Down Syndrome Social/Psychological Epilepsy/Seizure Disorder Visual Impairment Fragile X Partial Total Hearing Impaired TBI Partial Total Other Parent/Caregiver Information Information Custodial Parent/Guardian Relation to camper Home Phone # Cell Phone # Work Phone # Street Address (if different) City State Zip 2 nd Custodial Parent / Guardian Relation to camper Home Phone # Cell Phone # Work Phone # Street Address (if different) City State Zip Alternative Emergency Contact Relation to camper Home Phone # Cell Phone # Work Phone #

4 Camper s Care Information Mobility Walks Uses walker Uses wheelchair, can propel/drive self? Yes No Transfers No assists needed Needs assistance (explain): Assistive Devices None AFO s Glasses Hearing aid Helmet Other Communication No serious difficulties expressing thoughts or wants Has difficulties (explain): Uses sign language uses a communication device (what kind?): Eating No assistance needed Needs assistance (explain): Diet Normal Blended/Pureed Diabetic Food allergies (list) Special please attach a list of special diet so we can determine if we can meet your needs Bowel/Bladder Control No assistance needed Incontinent Needs assistance/schedule (explain): Aids used None Catheter Urinal Disposable undergarments Other Dressing No assistance needed Assistance needed (describe): Washing/showering No assistance needed Some assistance needed (describe): Total assistance needed (describe): Sleeping Typical sleeping habits Has trouble going to sleep Has nightmares Sleep walks Special bedtime routines: Usual bedtime: Usual wake up time: Individuals 16 and older may sleep on the upper bunk with parent or guardian s permission. To give your camper permission to use the upper bunk, please initial here: Camper s Social Background School/Employer Grade level Can the camper read? Yes No Write? Yes No Does the camper have any special behavior problems? Yes No If yes, please describe When do behavior problems occur? Describe effective methods to control difficult behaviors: Please list any fears the camper may have: Please list any activities the camper dislikes: What hobbies or activities does the camper enjoy at home and school? Please add any other information you feel would be helpful in providing the best experience for the camper while at camp: Camper s Health Information Medications Please list any medications the camper uses:

5 Seizures Yes No Type Frequency Describe any warning signs (aura) before seizures: **If camper is prescribed seizure medication they MUST bring the medication to camp. Allergies None Hay fever Poison Ivy Insect stings Asthma Penicillin Other Describe allergic reactions: Summary Please summarize camper s medical history: Psychiatric treatment/counseling Has the camper ever required any psychiatric treatment/counseling or hospitalizations? Yes No Please summarize (including dates): Shunt Does the camper have a shunt? Yes No List special instructions/limitations: Feminine needs Does the camper menstruate? Yes No Special treatments for cramps? List feminine products used and if they need assistance: Participation Please list any activity the camper may NOT Participate in or attach precautions or special instructions for routine activities: Insurance Information Is the camper covered by hospitalization insurance? Yes No Carrier: Policy/Group#: Medicare#: Medicaid#: A copy of the camper s insurance/medicaid, Medicare card or Military ID card must accompany this application. Please supply a copy of BOTH the FRONT and BACK of the card. Place copy of Front of Insurance Card here. Place copy of Back of Insurance Card here.

6 Referral Information Has the camper attended Easter Seals Tennessee Camp before? Yes No If yes, please list the years the camper has attended: If no, please indicate how the camper found out about Easter Seals Tennessee Camp: Family Member (name) other camper (name) School (name) Website (name) Social service agency (name) Other Do you know someone that would benefit from working at Camp? Name/contact Medical Form & Medication The completed Medical Form must be received by Easter Seals Tennessee Camp by 14 days prior to the first day of the Respite camper will be attending. Missing this deadline will result in the camper s reservation being voided and filled by another camper. In an effort to better serve our campers we require all campers to bring pre-package medications. This means all medications; vitamins and supplements brought to camp are prepared in a multi-dose bubble pack or medicine cassette for the duration of their stay. It is preferred that this is done in a bubble pack by a pharmacist. Please check all that apply Adults (ages 17 and up) Balance Due March (Respite) $ March 14 August 3-8 (TBI/Physical disabilities) $ July 4 August (TBI/Developmental disabilities) $ July 11 A $100 deposit is required per Camp; this is part of the total camp fee. Applications without the $100 deposit will not be processed. The deposit is non-refundable once the camper is accepted into the camping program. Camp balances are due 30 days before the camp or two weeks before a respite. please initial here. Respite Payment Options: Application check enclosed. $ on 1 Counselor - $200 (6 day camp) or $100 (weekend respite). Credit Card, if you would like to pay by credit card our staff will call once registration form is received at our office for the card information. We have applied for a scholarship with.

7 Waiver & Release The following section must be signed in ink by the adult camper/applicant/legal guardian of the adult camper or the legal guardian of the juvenile camper/applicant before the application can be processed: (1) Approval, Waiver and Activity Consent - This application has my approval. While Easter Seals Tennessee and YMCA Camp Widjiwagan will take every reasonable precaution, it is agreed that Easter Seals Tennessee and YMCA Camp Widjiwagan are not legally responsible for any accidents, incidents or injuries that may occur during the camp session, assumes no responsibility for applicant s personal property and are released from liability for any accident, incident or injury except as may be covered by camper s insurance. Applicant has my permission to engage in all camp activities, including transportation as deemed necessary, except as noted by myself or physician. (2) Medical Treatment - The undersigned hereby authorizes and grants permission to any licensed/certified medical professional designated by Easter Seals Tennessee and YMCA Camp Widjiwagan to provide routine medical care and administer medications or to perform any emergency procedures on the camper that would be jeopardized by any delay in providing such treatment or performing such procedures. (3) Media Release - I, the undersigned, in partial recognition of services rendered and benefits conferred by Easter Seals Tennessee and YMCA Camp Widjiwagan, its employees, agents and assigns, to release any pictures, or photographs taken of the above-named client for publication for purposes of conveying information concerning the named individual and/or Easter Seals Tennessee or YMCA Camp Widjiwagan. The undersigned hereby agrees also to hold Easter Seals Tennessee and YMCA Camp Widjiwagan harmless of liability should such pictures or photographs, either accompanied or unaccompanied by printed material, appear in other publication by whomsoever published, circulated or distributed. I understand that this authorization for media release is subject to revocation at any time, except to the extent that the media has been utilized. I also understand and agree that this release will terminate only upon the execution of my written statement on another sheet of paper indicating my intent to revoke this authorization. This can be stapled to your application. I ATTEST THAT ALL INFORMATION PROVIDED IN THESE APPLICATION MATERIALS INCLUDING THE APPLICATION, MEDICAL EXAMINAITON SUMMARY AND ANY SUPPLEMENTAL ITEMS ARTTACHED ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Legal Guardian/Adult Camper: Date: Print Name: Place Camper Photo here

8 2014 Medical Examination Summary Date of Examination: Date Form Completed: Easter Seals Tennessee Camp 3011 Armory Drive, Suite 100 Nashville, TN Phone: (615) ext 13 Fax: (615) APPLICANT S NAME: Date of birth: Gender: IMPORTANT NOTE TO PHYSICIAN: The information requested in this form is extremely important to the applicant s health and safety during participation at Easter Seals Camp. In most cases the level of activity will be higher than normal and the daily routine will be different. Camp has a health center on site staffed by a Camp Nurse; however, we are able to provide only routine, basic health care. It is crucial therefore, that care be taken in thoroughly completing this form. Thank you for your assistance in this matter. PLEASE CHECK THE FOLLOWING: Weight: Height: Blood Pressure: Vision: Hearing: Eyes: Ears: Nose: Throat: Teeth: Lungs: Heart: ABD.: Gent.: Skin: Lymph Nodes: Primary Diagnosis: (please be specific) Date of Onset: Secondary diagnosis (related or unrelated to primary diagnosis): Other Medical conditions (e.g. iliostomy): Any infectious diseases? Please name and give recommendations: Does the applicant have epilepsy?: Type of seizures: Frequency: Has the applicant been identified as developmentally delayed?: If yes please indicate level: Mild (IQ 69-55) Moderate (IQ 54-40): Severe/profound (IQ below 40): DOES APPLICANT HAVE ANY ALLERGIES?: To: Bee Sting or insect bite Pollen Serum: Food: Drugs (penicillin, etc.): Other: Signs of allergic reaction: Recommended treatment: DIET: Does applicant have any medically prescribed meal plan or dietary restrictions? Please describe: CAMP ACTIVITIES: Please include any instructions or precautions to be taken during routine camp activities. These activities may include swimming, horseback riding, canoeing and sports: Please list any activities in which the applicant may NOT participate:

9 Reactions that might be expected with irregularities in: A. Environment B. Diet C. Medications D. Stress Medical History: Dates of Immunizations: Measles, mumps, rubella: Tetanus-diphtheria Toxoid: H. influenza: Pneumonia: Last TB Skin Test Date: Results: DPT series: Polio series: Chicken Pox 1. Hepatitis B: Last dates applicant has had: Chicken pox: Mumps: Diphtheria: German measles: 10 Day measles: Whooping cough: Strep throat: Pneumonia: Rheumatic fever: Mononucleosis: Does applicant have a history of: Ear infections: Strep throat: Gastric upsets: Mono: UTI: Kidney problems: Eczema: Hypertension: Diabetes: Other: Emotional upset: SIGNATURE OF PRIMARY HEALTH CAREGIVER: The following information could be crucial in an emergency situation. Please print or type clearly. NAME OF PRIMARY HEALTH CAREGIVER: ADDRESS: CITY: STATE: ZIP: PHONE: ( ) Medical professional to contact in the event applicant s Primary Health Caregiver cannot be reached: Name and title: Phone number: _ ( ) Address: