2018 Camper Application Packet

Transcription

1 2018 Camper Application Packet Dear Parents and Guardians: Camper applications can be submitted ONLINE at It is a pleasure to inform you that the Double H Ranch is beginning preparations for the 2018 summer camp season! There is no charge for your child to attend camp. However, transportation expense and arrangements are the responsibility of the individual families. To attend Double H Ranch, your child must meet the following admissions criteria: 1. Have a diagnosis of cancer, sickle cell anemia, hemophilia, von Willebrand s, HIV, collagen vascular disease, inflammatory bowel disease, mitochondrial disease and selected neuromuscular impairments. 2. Must be ages 6-16 for regular sessions (one - seven) and ages and prior Double H camper for Alumni Session. 3. Child must function at a cognitive age of at least 6 years old. Please complete the entire parent portion of the application - answer all questions and sign BEFORE returning to the Admissions Office. Remember to give your child s doctor ample time to complete the required medical forms. Please only submit one copy of your child's application - a hard copy is preferred (mail or scan / ). Faxed copies are often difficult to read. Be sure your child s name is written on the top of EVERY page of the application. We use a rolling admissions process. While we wish we could accommodate everyone, we are unable to guarantee enrollment. Acceptance is based on a first come, first serve basis in addition to medical criteria focusing on the needs of the child and our ability to provide safe, medically sound, and fun camp programing Dates Session 1: June 21 - June 26 (sibling) Session 2: June 29 - July 4 (sibling) Session 3: July 7 - July 12 Session 4: July 16 - July 21 Session 5: July 24 - July 29 Session 6: August 1 - August 6 Session 7: August 9 - August 14 Alumni : August 16 - August 20 We realize Session 1 starts before the end of most New York State public schools. Many factors contribute to the summer camp calendar - we appreciate your understanding!

2 Frequently Asked Questions How much does it cost to send my child to the Double H Ranch? All our campers attend HH for free! Our generous donors cover all operating costs for all programs. Can I stay or visit with my child while he/she is at camp? The Double H is a residential camp program (lasting 6 days) for children. Visits are discouraged because not all campers have visitors and it is difficult to pull the children out of their scheduled program activities during the day/night. There is a talent show / wish boat ceremony on the last night of each session that family members are invited to attend. Your child s summer confirmation packet will provide more details. If items are missing from the application, will I be notified? Yes, an or postcard will be sent home with the status of the child's application and any missing items that are needed. How will I know when my child has been accepted to Double H? Starting April 15th, applications that have been approved by the medical team will have a confirmation packet ed or sent home with your child's summer session date. To ensure a successful week at camp, there will be forms in the packet that need to be sent back to camp before your child arrives. If there aren't any changes to your child's medical status or medication since the application was submitted, please disregard that form only. How is transportation organized? If the child is taking group transportation provided by the hospital, speak directly to the hospital for the travel schedule. Please indicate the hospital name on his/her application. Otherwise, transportation is the responsibility of the family (including bus or train ticket purchasing). If your child is taking the public bus or train to camp, please call the Admissions Office with your child's arrival time/departure time so we have a counselor there to greet him/her. What time should we arrive on the first day and depart on the last day of camp? Arrival Day check-in is between 11am-1pm. Departure Day check-out is between 9-10 am. Alumni Session check-in is between 1 pm - 3 pm. Departure Day check-out is between 9-10am. If I have a question who do I call? Applications should be mailed to: 1. Admissions Hospital Groups: Tara Bogucki Admissions Director tbogucki@doublehranch.org (518) x 222 Individual campers: Julia Kusnier Family Coordinator jkusnier@doublehranch.org (518) x Medical Emo Castle Nursing Director nursing@doublehranch.org (518) x Camp Operations Jacqui Royael Director of Operations jroyael@doublehranch.org (518) x 225 The Double H Ranch 97 Hidden Valley Road Lake Luzerne, NY Phone: (518) x222 / x263 Fax: (518) Web: Please do not send duplicate copies of application!

3 Double H Ranch A SeriousFun Camp 97 Hidden Valley Road Lake Luzerne, NY Phone:(518) Fax:(518) SESSION REQUESTED (choice of session not guaranteed) First Choice Second Choice Third Choice Camper's Name Today's Date / / Nickname! M! F Age Date of Birth / / Address (street) Apt. # City State County Zip code Primary Language If NOT English, does camper speak English?! YES! NO Diagnosis How did you learn about camp? Have you participated in our Hospital Outreach Program, Camp on the Go?! YES! NO Attended overnight camp before?! YES! NO Where? When? The Double H Ranch is made possible through generous donations and grants from public and private organizations. The following information is for demographic purposes only and will be used to help fund our programs. These are optional and all answers will remain anonymous and confidential. Does your child qualify for the Free / Reduced Price School Meals? YES! NO! Ethnicity:! African American! Latino! Caucasian/White! Asian/Pacific Islander! American Indian! Other Who has Legal Custody of this child? Name of parent(s) or guardian(s) child lives with Camper Application Summer 2018 Contact Information For Office use only APPROVED for camp:!yes!no Conditional on Crypto!Yes!No Signature Date / Parent/Guardian 1 Home phone# ( ) Address Cell phone# ( ) City State Zip Work phone # ( ) X address Employer Parent/Guardian 2 Home phone# ( ) Address Cell phone# ( ) City State Zip Work phone # ( ) X address Employer Sibling (s) / Ages EMERGENCY CONTACT (OTHER than Parent/Guardian and must be >18) Name Relationship to child Phone# ( ) Alternative Phone # ( ) Transportation Transportation to and from camp, please check one:! Family! Hospital group transport Hospital name Social Worker! Airplane (Albany Airport)! Train (Saratoga Springs, NY)! Public Bus (Glens Falls, NY) * Please call the office with camper's pick up / drop off time for transport (bus/train/airplane) * 1

4 Physician Contact Information Specialist Pediatrician/Other Dr. Institution Institution Address Address City State Zip City State Zip Phone # ( ) After hours # ( ) Phone # ( ) After hours phone # ( ) Fax # ( ) Fax # ( ) Designated contact from referring hospital /agency Phone # ( ) After hours phone # ( ) Insurance Information A copy of campers UPDATED insurance card is REQUESTED. PLEASE include prescription card if applicable. Company Plan or group # Cardholder Name BIN # PCN # ID # Other Immunizations Chicken Pox 2 doses REQUIRED unless contraindicated! Clinical Disease Date (Diagnosed by MD)! Varivax Vaccines Dates (2 doses)! Positive Titer Date! Camper is NOT IMMUNE and the vaccine is contraindicated Reason contraindicated Polio Campers must have completed polio vaccines; 3-4 doses Is this series complete?! YES! NO Meningitis Required for 11 years old Booster required 5 years after first dose Must be (Menactra, Menveo,MCV4) Type Date Type Date MMR 2 doses REQUIRED unless contraindicated MMR 1 Date MMR 2 Date Positive Titer Date Tetanus and Pertussis 6-10 years old Must have had a least 4 DTaP with the last dose at age 4 or older. 4 doses total of DTaP! YES! NO Date of last DTaP years old must have at least 5 doses with a Tdap booster at age 10 or older and not more then 9.5 yrs pre camp. 5 doses total! YES! NO Date of last Tdap Recommended We strongly recommend the following vaccines. HIB (Hemophilus) immunized?! YES! NO Pneumococcal vaccine Date(s)! Prevnar (PCV7 or13)! Pneumovax Hep B vaccine Date(s) Hep A vaccine Date(s) 2

5 General History Does camper have any drug allergies?! YES! NO If yes, to what drug and what reactions 2 Does camper have any food restrictions or food allergies?! YES! NO If yes, please explain Do they require a special meal plan?! YES! NO 3Does camper have any environmental allergies?! YES! NO If yes, please explain 4 Does camper have any additional medical problems (such as asthma, developmental delay, hearing or vision loss)?! YES! NO If yes, please explain 5 Does camper have difficulty with control of urine or bladder function (such as incontinence, diapers, need for catheterization)?! YES! NO If yes, please explain (including frequency) 6 Does camper have problems with control of stool (bowel movements)?! YES! NO If yes, please explain (include frequency) 7 Does camper have seizures?! YES! NO If yes, please describe When was the last seizure? How frequent are the seizures? Is any treatment needed? 8 Does camper have any physical limitations / mobility devices? Wheelchair Power wheelchair crutches walker AFO's! YES! NO If yes, please explain 9 Does camper have a sleep apnea monitor, other monitoring devices, or is your child on CPAP or BiPAP? *Please note campers on BiPAP can only attend Camp Inspiration, we have specific criteria for a limited number of campers on CPAP during general sessions.! YES! NO If yes, please explain 10 What is campers means of communication? VERBAL NON-VERBAL USES SIGN LANGUAGE USES ASL USES ELECTRONIC DEVICE (please bring to camp) 11 Camp programs are designed for children who cognitively function at a 6-16 year old level. At what developmental age does camper function? 1-3 yrs old 4-5 yrs old 6-8 yrs old 9-10 yrs old yrs old yrs old yrs old yrs old 12 Does your child have pain? If Yes how do you manage it at home?! YES! NO Please explain LEVEL OF ASSISTANCE FOR YOUR CHILD PLEASE MARK APPROPRIATE COLUMNS Independent Minimal Assistance Moderate Assistance Total Care (1: 1) Daily Care (teeth, hair, dress) Meals Bathing/Showering Toileting / Bathroom 3

6 Behavior Information 2018 Please help us to understand your child by answering the following questions: 1 Please describe your child s strengths and personality. Include how they relate to adults and children. _ 2 What makes your child upset? When your child is angry / frustrated, describe how they handle anger. _ 3 What techniques do you use to handle behavior issues (rewards, timeout, etc)? _ 4 Tell us about your childs bedtime routine:! Bedwetting! Bed rails! Sleep walking! Difficulty falling asleep! Does not sleep alone! Nightmares! Nightlight! Bed Time : 5 Has your child ever been diagnosed with:! ADD / ADHD! Conduct Disorder! Autism Spectrum Disorder (PDD, Asperger's Syndrome)! Eating Disorder! Depression! Reactive Attachment Disorder! Bipolar Disorder! Other 6 Has your child ever been prescribed behavioral medications (including ADD meds, antidepressants, etc)?! YES! NO If yes, what medications? OVER 4

7 Behavior Information Continued Family - Have there been any recent changes?! Divorce! Moving! Illness / Death! New sibling EXPLAIN: Personal issues - Has your child experienced any of the following?! Difficulty relating to peers! Changes at school! Recent hospitalizations! Issues with illness EXPLAIN: Depression/Anxiety - Has your child been treated for any of the following?! Depression! Suicidal thoughts! Suicidal Attempts! Violence! Anxiety! Other Has this treatment required hospitalization?! YES! NO If yes, where? When? Has the problem improved with counseling or meds?! YES! NO Explain: If further information is required, please provide the name and phone number of your child s psychological services: Contact Name, Credentials ( ) - Phone School- Does your child have a 1:1 aide at school?! YES! NO Has your child had any trouble at school such as being bullied?! YES! NO Or bullying others?! YES! NO Has your child been convicted of a crime?! YES! NO Explain: How do you feel any of the above might affect your child's time at camp? / / Parent/Guardian Signature Mandatory Printed Name Date 5

8 Mandatory Permissions 2018 Please carefully consider granting these permissions. We are available to discuss further details of activities. If you have questions please call our Director of Operations. For many activities we also require additional physician permission for campers to participate. 1 May your child participate in a supervised, structured swimming program in a heated pool?! YES! NO Are ear plugs needed?! YES! NO 2! I DO! DO NOT give the Double H Ranch, SeriousFun Children s Network, Inc., their respective affiliates and the parties permitted by them (collectively, the Recipients ) permission to photograph and/or videotape my child, and to use my child s name, likeness, image, and/or video in promotional materials, including fundraising, marketing, and educational materials. I understand that my child s name, likeness, image, and/or video may be used to promote public understanding and support of programs for children with critical illnesses, and that the materials containing my child s name, likeness, image, and/or video may be used in the current year and/or in future years. This consent may be revoked in writing at any time, except to the extent that the Double H Ranch has already relied upon it in making use of my child s name, likeness, image, and/or video. I understand that this consent is not a condition of participation in the program. 3! YES! NO Double H is allowed to give out my child's name and address to summer cabin campers, staff and volunteers who are interested in maintaining contact throughout the year. It is my understanding the purpose is to allow campers to connect with each other throughout the year. By saying yes, your child s name and address will be included on the contact list given to campers. 4! YES! NO May your child go offsite to the Six Flags Great Escape Amusement Park accompanied by Ranch staff?! YES! NO May your child participate on mild rides, such as the train or sky ride?! YES! NO May your child participate on thrill rides, such as roller coasters?! YES! NO May your child participate in the water park? 5! YES! NO May your child participate in horseback riding, at walking speeds where horses are always on lead? 6! YES! NO May your child participate in a supervised high ropes course program with certified staff? 7! YES! NO May your child participate in a supervised archery program with certified staff? / / Parent/Guardian Signature Mandatory Printed Name Date DELEGATION OF AUTHORITY TO CONSENT FOR MEDICAL TREATMENT OF MINOR This document constitutes a designation of person in parental relation for a period of not more than 30 days, in accordance with Title 15A of the New York General Obligations Law. Name of minor child: 1. By signing this document, I/we authorize the Executive Director of the Double H Ranch and/or the Executive Director s designee(s) to make health care decisions with respect to the above named child during the period while this designation remains in effect. 2. This designation takes effect during the 2018 summer session the minor child is at Double H Ranch. 3. I understand that I may revoke this designation at any time. 4. The Executive Director of the Double H Ranch and the Executive Director s designee(s) are authorized to use and disclose health information concerning my child to the extent necessary and relevant to making health care decisions under this designation. 5. There is no court order currently in effect that limits my authority to make health care decisions for my child or to make this designation. 6. Comments / limitations [optional]: * If a court order requires that both parents agree on healthcare decisions, both parents must sign this form. * In cases where a parent or legal guardian is unavailable or child is in the custody of any agency, the above is to be signed by placing agency (Commissioner of Social Services) or designee. / / / / Parent/Guardian Signature Mandatory Date Parent/Guardian Signature Mandatory Date Print Name Relation Print Name Relation 6

9 Camper Physical Exam Form Page 1 Summer 2018 Today's Date / / Date PE based on / / *If child has been hospitalized or had surgery in the last 12 months, please provide a copy of the discharge summary. Primary Diagnosis: Date of Dx / / Secondary Diagnosis/Problems: List Surgeries: If Cancer, is child still on Chemotherapy?! YES! NO When was chemo completed? / / Allergies: Drug Food or other Allergies Does child have any of the following:!central access If YES, Type: Location: *Please submit CVL Form!Trache!On O2!CPAP/BiPAP!Shunt!G Tube/J Tube!Baclofen Pump!Mitrofanoff!Malone ACE Vital Signs: Ht in / cm Wt lb / kg BP HR RR Has child had any infections with resistant organisms? YES! NO! if yes, please explain: Checklist Mandatory: Check If Normal, or give details of abnormalities below.! HEENTN:! Respiratory:! Cardiovascular:! Gastrointestinal / Renal:! Musculoskeletal:! Neurological:! Skin:! Genitalia & Rectum: Seizures:! YES! NO if YES, Frequency Type Treatment: Behavioral Issues:!AD(H)D!Oppositional!Eating Disorder! Other Comments: 7

10 Camper Physical Exam Form Page 2 Summer 2018 MEDICATIONS Each family should send all medications and medical supplies necessary for their child while at camp. The medical staff will store and administer medications as directed by you. *Please note: Standard Med Times are Breakfast, Lunch, Dinner, Bedtime. Is camper on any Clinical Trial Medications?! YES! NO If yes, we will contact you for additional information. Medication Name Dose Route Frequency / Time Please include information about medications used to prevent nausea and vomiting and pain management if applicable. Additional Comments / limitations? Physician's Statement: I have examined who is physically able to engage in all camp activities; including our Adaptive Winter Sports Program and rides at the Great Escape Park except for physical limitations and restrictions previously stated. I agree with continuing the above medical regimen while at camp. For detailed information about camp activities, please see our Physician Information Sheet available on our website or through our Admissions Department. MANDATORY Signature of Physician PRINTED Name Institution Address City State Zip Phone # ( ) After hours phone # ( ) Fax # ( ) 8

11 Neuromuscular Disorders Form 2018 Please fill out for campers with Spina Bifida, Stroke, Muscular Dystrophy, Cerebral Palsy, etc. 1 How is this camper affected? 2 Any problem with head control?! YES! NO If yes, please explain 3 Mobility (tires easily, difficulty balance etc.) 4 Does your child have any problems with temperature control?! YES! NO If yes, please explain 5 Is catheterization needed?! YES! NO Frequency: Does your child self cath?! YES! NO 6 Does camper have frequent urinary tract infections?! YES! NO If yes, how frequent: 7 Is feeding assistance needed?! YES! NO! Chopped diet Other special diet: G- Tube feeds! YES! NO 8 Bowel Habits: Chronically constipated?! YES! NO Requires enemas / suppository?! YES! NO How often does camper have a bowel movement? Diapers or Attends needed?! YES! NO 9 Skin integrity: Are there any areas of pressure sores or other skin problems?! YES! NO If yes, please explain Treatment 10 Does camper have a Baclofen Pump?! YES! NO Date of last change in rate or dose / / 11 Other pertinent information that will help us care for your child? / / Parent/Guardian Signature Mandatory Printed Name Date

12 Hemophilia Form 2018 Weight Kg Orders based on / / Type! Hemophilia A (Factor 8)! Hemophilia B (Factor 9)! Hemophilia C (Factor 11) Severity! Severe! Moderate! Mild Baseline level Factor Product Half life of factor Trough level prior to next dose 24 hour level (for extended release) Is camper on any study drugs?! YES! NO Inhibitor?! YES! NO Access:! Peripheral! Port Does camper self infuse?! YES! NO MAJOR bleeds (joints / head injury / trauma) Units MINOR bleeds Units Prophylaxis! YES! NO dose: units (circle day(s)* SUN MON TUE WED THU FRI SAT *We will adapt prophy days to fit activities unless you specify otherwise. ACTIVITIES that child requires prophylactic infusion for: Activity Permission Pre Treatment If YES, what treatment: Great Escape Park Due to rides with high G-forces and risk of CNS bleeds we REQUIRE Treatment AND permission from camper s Hematologist for ALL campers with hemophilia to ride high G-force rides. Permission to ride roller coasters & other rides with high G-forces? Permission to ride other rides? REQUIRED for high G-force rides 100% dose required for Moderate and Severe to ride high G-force rides. For Mild treatment per Hematologist required. Units High Ropes Course Due to high G-forces on Giant Swing we recommend 100% for severe and moderate Permission for high ropes course? Permission for Giant Swing (high G-force element) Units Any additional comments or special needs : Please note all activities with the exception of Great Escape take place within minutes of the Body Shop where rapid medical assessment and factor infusions are available should a camper sustain an injury. Nurses are present at all offsite activities. The camp physician and nurses accompany the campers to Great Escape. Our camp Pediatric Hematologists and Medical Director know all camp activities very WELL and have made the above recommendations for pre- treatment. For details on our activities, please see our Physician Information Sheet available on line or through our Admissions Department. NOTE: Campers must BRING to camp ALL the factor and supplies they will need for the above infusions. Additionally, they MUST bring ONE - TWO 100% correction doses for emergency use. MANDATORY Signature of HEMATOLOGIST PRINTED Name Institution Phone # ( ) After hours phone # ( ) Fax # ( ) Double H Ranch* 97 Hidden Valley Road * Lake Luzerne, NY 12846* FAX (518)

13 All Other Bleeding Disorders (Non - Hemophilia) Form 2018 Weight Kg Orders based on / / vonwillebrand's! Type I! Type II! Type III Anticoagulant Use! YES! NO Platelet Disorder Thrombocytopenia average count Briefly describe clinical bleeding Please indicate what medications and doses are used to treat bleeding: How many days of treatment are usually required? We do not routinely use prophylaxis prior to activities in this group of patients. If prophylaxis is needed, please check off which activities; and specify what drug & dose to use. For details on our activities, please see our Physician Information Sheet available on line or through our Admissions Department. Activity Permission Pre Treatment If YES, what treatment: Great Escape Park Roller coaster rides and other rides with high G- forces and risk of CNS bleeds High Ropes Course High G-forces on Giant Swing Permission to ride roller coasters & other rides with high G-forces? Permission to ride other rides? Permission for high ropes course? Permission for Giant Swing (high G-force element) Special concerns: MANDATORY Signature of HEMATOLOGIST PRINTED Name Institution Phone # ( ) After hours phone # ( ) Fax # ( ) Double H Ranch* 97 Hidden Valley Road * Lake Luzerne, NY 12846* FAX (518)

14 Sickle Cell Disease Form 2018 Weight Kg Orders based on / / Sickle cell disease is one of the most challenging diseases we have at camp given the disease's inherent unpredictability. Please give us as much information as possible to help us make the child's camp experience enjoyable. We would welcome a copy of his/her most recent clinic visit or hospitalization. For more details on our activities see our Physician Information Sheet available on line or through our Admissions Department. Please note our camp protocols are available for review through our Admissions Department. The following is ESSENTIAL for us to properly care for your patient: Diagnosis (SS, SC, etc.) Baseline CBC: Hgb WBC Retic Baseline Pulse Oximetry: Is camper fully immunized to PCV 13! YES! NO Splenomegaly! YES! NO Size Splenectomy! YES! NO Year Stroke! YES! NO Year Current neuro exam Acute Chest! YES! NO Most recent date Cholecystectomy! YES! NO Avascular Necrosis! YES! NO Location Priapism! YES! NO Treatment Sepsis! YES! NO Details Hospitalized! YES! NO Details in the last 12 months Is this camper on a chronic transfusion protocol? Does this camper have a port? (Please consider a transfusion the week prior to camp to allow for maximum camp enjoyment) Activities: Please indicate if this child is able to participate in the following activities: Swimming heated pool (>87 degrees) Water park at Great Escape Amusement Park (water park pools are not heated) MANDATORY Signature of HEMATOLOGIST PRINTED Name Institution Phone # ( ) After hours phone # ( ) Fax # ( ) Double H Ranch* 97 Hidden Valley Road * Lake Luzerne, NY 12846* FAX (518)

15 Immune Disorder Form Does child know diagnosis? YES! NO! Please elaborate briefly: *While we realize and enforce the importance of confidentiality and discretion regarding diagnoses, we cannot control conversations among campers. 2. Most recent blood counts Date / / WBC Hgb Hct Retic Plt ANC Viral load CD4 + cell count % 3. Recent transfusion? When Dose If more than one transfusion, when was previous one? 4. Is child receiving IVIG?! YES! NO *Please note we can not administer IVIG at camp. 5. Has the child had PCP or other opportunistic infections?! YES! NO If yes, when Diagnosis Tx 6. What is the child's PPD or Quantiferon testing status:! Negative! Positive Date / / (Required within 10 months of camp session date) If positive, date of CXR and treatment If positive we require physician confirmation that camper is not contagious;! Camper is not contagious 7. What is the child's Neuro status?! Normal Other 8. Is this child known to have Cryptosporidium in the stool?! YES! NO 9. Are there outstanding psychosocial issues the camp should be aware of? 10. Please explain the system used for giving/taking medications (w/juice, crushed in pudding, etc.) MANDATORY Physician Signature PRINTED Name Institution Phone # ( ) After hours phone # ( ) Fax # ( ) Double H Ranch* 97 Hidden Valley Road * Lake Luzerne, NY 12846* FAX (518)

16 Central Venous Line (CVL) Form 2018 FILL OUT THIS FORM ONLY IF THIS CHILD HAS A CENTRAL LINE CATHETER (BROVIAC/HICKMAN, PORTACATH, ETC.). 1. Type of catheter:! (External) Broviac/Hickman! (Internal) Portacath/Infusaport! Other 2. Specific instructions for catheter care: How often is CVL flushed? What solution is used to flush / lock the line? What amount & strength is used? What size needle is used for access? gauge length How often is dressing changed? 3. Does this child do any or all of their own catheter care? 4. May this line be used to draw blood? 5. What, if any, medications are to be infused into this line during the camp period? *Please send all necessary supplies (dressing kits, flushes, needles, syringes, etc.) with the child to camp. Children will need at least 5 dressing kits (or equivalent supplies) if they plan on swimming every day.* CENTRAL LINE PERMISSIONS This child has permission to take a shower This child has permission to go swimming in a chlorine treated swimming pool. A dressing change will be done immediately following swimming. MANDATORY Physician Signature PRINTED Name Institution Phone # ( ) After hours phone # ( ) Fax # ( ) Double H Ranch* 97 Hidden Valley Road * Lake Luzerne, NY 12846* FAX (518)

17 Infusion Pump Form 2018 FILL OUT THIS FORM ONLY IF THIS CHILD USES A TPN PUMP, GASTROSTOMY FEEDS PUMP, ETC. *Be sure to send pump and extra batteries (enough for every night plus one extra night's worth), enough sterile water, Desferal and needles for the whole session. 1. Manufacturer and model of pump: (Please provide pump operator manual) 2. Procedure to replace broken pump: Special number to call: 3. Which days of the week will the pump be used while at camp? 4. Instructions for gastrostomy feeds: Type of feed given how frequently Is extra water given? How much/when? starting rate /min x hrs (taper up) maint. rate /min x hrs ending rate /min x hrs (taper down) 5. What time is the pump usually started? stopped? 6. Home care company and phone number (if used): 7. Any special instructions: MANDATORY Physician Signature PRINTED Name Institution Phone # ( ) After hours phone # ( ) Fax # ( ) Double H Ranch* 97 Hidden Valley Road * Lake Luzerne, NY 12846* FAX (518)