FEE. (circle one) T-Shirt Size: XXL. Height: Weight: Phone Number: Relationship: $375 $400 $25. Non-CPI Participant. Transportation $25) $75 $10

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1 Camp Partnerships Application 2018 This information is EXTREMELY important in helping to provide a safe and enjoyable time for each camper. Pleasee answer ALL questions completely and honestly. If ALL questions are not completed, this application may be returned and therefore forfeiting reserved space. Campers Name: Sex: Birthday: Height: Weight: Phone Number: Address: City: Zip: Campers Legal Guardian: Relationship: Please put a 1 on your first week choice and a 2 on your second week choice. It is first come; first serve and we will do our best to accommodate, however, it is ultimately up to Community Partnerships to assign the campers to a week. FEE July INFORMATION Please check all boxes thatt apply and add total CPI Participantt. Non-CPI Participant Transportation... ( Round Trip, Just to Camp, Back from Camp ALL $25) White Water Rafting. Zipp Line. (Camper must have signed release for the zip line!!) **Make checks out to Community Partnerships and put the word camp and the campers name in the memo line** or July 28-Aug 1 $375 $400 $25 Administrative Purposes: Total fee enclosed Initials: Total fee paid no later than 6/5/18 Already Paid- Cash Check Date: : $75 $10 TOTAL: $ T-Shirt Size: (circle one) S M L XL XXL 3X 4X Camp Partnerships Check List Please make sure ALL of these things are done to allow attendance at camp!! Application (completely filled out) Scheduled Med list (signed by MD) $$ payment $$ PRN med list (signed by MD) Picturee of Camper Zip Line Release Return the completed application to: or Please mail completed application to: ATTN: TERONDA Community Partnerships of Idaho 3076 N Five Mile Rd Boise, Idaho med sheets SIGNED BY A MEDICAL DOCTOR to allow entrancee into Camp Partnerships

2 ***WE REQUIRE A CURRENT PHOTO FOR THE CAMPER S NAME TAG & SAFETY PURPOSES**** (YOUR APPLICATION IS NOT CONSIDERED COMPLETE WITHOUT IT!!) Our preference is a digital picture but you can attach a current photo to this application camp@mycpid.com (Include the camper name in the subject line) This application has my approval. While Community Partnerships of Idaho Inc. will take every precaution, it is agreed that Community Partnerships is not legally responsible for any accidents, incidents of injury that may occur during the camp sessions, assumes no responsibility for campers property and is released from liability for any accident, or injury except as may be covered by campers insurance. **Please notify Community Partnerships of Idaho if the camper is exposed to any communicable disease during the three weeks prior to camp attendance. ** Permission is hereby granted to any licensed professional designated by Community Partnerships of Idaho to treat or perform any emergency operation and/or treatment, when, in the opinion of such professional, the campers condition would be jeopardized by any delay in providing the needed treatment and/or operation. Also, Community Partnerships will be taking pictures and video s of campers and staff during activities at Camp Partnerships. These pictures may be used in a CPI brochure, scrapbook, CPI Facebook, CPI Website, etc. I am giving my consent for Community Partnerships of Idaho to take pictures or video at camp that may be used in as above mentioned. I understand that my consent releases Community Partnerships of Idaho for all liability associated with public exposure. Camper Signature: Date: Witness: Witness: If the camper has a legal guardian, the guardian MUST sign below: Guardian Name: Date: Guardian Signature: **If the camper is accepted for Camp Partnerships, it is understood that they will remain the full period of time and NO refund will be made unless two weeks notice prior to camp is given. A $50 processing fee will be withheld from the refund. If deemed necessary for the camper to leave camp, it becomes the full responsibility of the camper guardian or caregiver to assume responsibility including transportation and/or finances required to get the camper home.***

3 Primary Diagnosis: (Please be specific) Secondary Diagnosis: EMERGENCY INFORMATION (Who to contact in case of emergency, Primary and Secondary) Primary Name: Relationship to Camper: Phone #: Secondary Phone #: Secondary Name: Relationship to Camper: Phone #: Secondary Phone #: Medicaid: Y N Medicaid Number: Insurance: Member Number: Phone Number: Who has permission to pick up the camper either on closing or earlier if necessary? Name: Relationship to Camper: Phone #: Secondary Phone #: Communication What is the camper s primary means of communication? Please check all that apply. Spoken/Verbal Sign Language Points to Needs/Gestures Picture Boards : Does the camper have trouble communicating needs and thoughts? If yes, how can we assist them? Social Background, Interests, Restrictions Has the camper been away from home before? Approximately how many times: Reactions/Suggestions/Problems Have they been to other camps, if yes, when & how many years? What hobbies/activities do they enjoy at home/school/free time? Please list any activities the camper should NOT participate in or special instructions for camp activites: Does the camper have any other specific fears? If yes, what? Please add anything else about home/school etc. that would help the camper get along with others and enjoy camp: Are they comfortable in water above their head? Y N Do they like being in a lake? Y N Does the camper know how to swim? Y N

4 Allergies Y N (medication, food, and environmental) If YES, fill out table Allergy Reaction Treatment Medical History (Please check any that apply, with explanation & date. If more space needed, attach a separate piece of paper with explanation) Medical Issues Explanation Medical Issues Explanation Abdominal pain Anemia Anxiety Arthritis Asthma Blood disease Bladder Problems Bowel Problems Breathing issues Cancer-Where/When Diabetes- Insulin Dependent? Epilepsy GI reflux (GERD) head injury Headaches Hearing problems Heart problems Heart surgery Hepatitis Hernia High/Low Blood pressure Kidney stones Nausea/vomiting Overeating Pace maker Seizures Skin rash Sleeping Issues Stomach ulcers Stroke Teeth problems Thyroid disease Vision problems

5 Seizures (If YES, all questions in this section MUST be answered!!!) Does the camper have any type of seizures, both present or past? Y N Types? Date of last seizure? Aura or warning before seizures, describe? Does anything cause the campers seizures, describe? How long typically do the seizures last? On medication for seizures, if yes what? Vagal Nerve Stimulator (VNS)? Y N Where is the VNS? How long, if camper seizes, until we call 911? What needs to be done after a seizure? Approximately how long does it take for the camper to get back to normal after seizing? special instructions? Bathing/Showering/Dressing Does the camper require assistance in showering? Y N If yes, explain Does the camper require assistance in dressing/undressing? Y N If yes, explain Does the camper require assistance with brushing their teeth? Y N Does the camper require assistance with brushing their hair? Y N If the camper is male, does the camper require assistance in shaving? Y N Does the camper use any of the following: Dentures Y N Glasses Y N Contacts Y N Hearing Aids Y N Is there any other info that would help us? Sleeping Does the camper have trouble sleeping? Y N If yes, what works at home? What is the usual bedtime? What is the usual bedtime routine? Can the camper sleep on the top bunk? Y N Does the camper use a sleep apnea machine? Y N Does the camper sleep-walk? Y N Does the camper have a history of bedwetting? Y N Is there any other info that would help us?

6 Eating The camp does a great job cooking food all week for our campers and staff. However, please remember that camp is the campers vacation, so unless it is medically or behaviorally necessary, please remember to allow some wiggle room for improving their camp experience for the week. Typical Diet: Are there any foods the camper WILL NOT eat? Does the camper have any special dietary restrictions? Y N What are the restrictions and why? Does the camper require any assistance in eating? Y N If yes, please explain Has the camper ever had an eating disorder? Y N Anything else we should know about the campers eating habits? Toileting Does the camper need assistance using the restroom? Y N If yes, explain Is the camper incontinent during the day? Y N Is the camper incontinent at night? Y N Are scheduled restroom breaks needed? Y N Does the camper have problems with diarrhea/constipation? Y N Typical treatment? FEMALES: Does the camper have a menstrual cycle? Y N Des the camper require assistance with using pads/tampons? Y N Does the camper get cramps? Y N If yes, treatment? Mobility Is the camper ambulatory? Y N Does the camper use a walker, crutches or cane? Y N If yes, which one? Does the camper have difficulty walking? Y N Why? How far can the camper walk without stopping? Does the camper use assistive devices? ie: braces, cane, etc. Y N (If yes, please answer following questions) What devices are used? How long should they be worn? Can the camper walk without them? Y N Does the camper need assistance getting them off and on? Y N Does the camper use a wheelchair? Y N (If yes, please answer following questions) Assistance in pushing needed? Y N

7 Assistance in transferring? Y N Can the camper put weight on their feet? Y N Please explain how they transfer and anything that would help us Normal Behavior and Behavioral Concerns Explain the campers general behavior and mood s (happy, shy, cautious, outgoing ect.) Does the camper interact well with others? Y N Does the camper tolerate loud noise levels? Y N Does the camper prefer to be alone? Y N If the camper is angry/upset what do they do? And how often does this occur? Does the camper have any behavioral concerns? Y N If yes, explain

8 Additional Info Has the camper been hospitalized in the past year? Y N If yes, for what and date? Has the camper had any recent injuries or illnesses? Y N If yes, explain Give approximate date of last tetanus booster: Does the camper smoke? Y N If yes, what kind (vape, cigarettes)? Does the camper have any implanted medical devices? (I.E.: shunt, pacemaker, defibrillator, ear tubes, VNS etc? Y N If yes, what/where and special instructions? Does the camper have any medical equipment? Y N If yes, what? (If excessive medical equipment are needed an additional fee may be charged) Does the camper have any infectious diseases? Y N If yes, what? Does the camper have any other pertinent history or information we need to know to take care of them? Y N If yes Please fill this out even if you are unsure if your camper will participate. They will not be forced to do anything they don t want to do, but if we don t have this and they want to participate they can t.