SEA TO SKY SEA TO SKY APHASIA CAMP 2014 Dear Campers: We are excited for you to join us at the 5th Annual Sea-to-Sky Aphasia Camp! We hope to have a fun and relaxing weekend. DATES: September 12-14, 2014 PLACE: Easter Seals Camp in Squamish Easter Seals Camp is 45 km north of Vancouver. The camp is 33 acres. There are large sports fields and an indoor heated pool. The camp is surrounded by natural woods, hiking trails, and lakes. There are two lodges at the camp. Each lodge has room for four - six people or two couples. Each lodge also has bathrooms and showers. The camp is largely wheelchair accessible. We look forward to seeing you at registration from 2:00-4:00 pm on Friday, September 12 th. We will do our best to make your camp experience the best ever! Please fill out this registration package. Please return Forms D, E, F, G, H, I, J by: 1. EMAIL: sil2@howesound.net 2. FAX: 604.936.9003 3. MAIL: Attn: Andrea Serrer #400-906 Roderick Avenue Coquitlam, BC V3K 1R1 Fax: 604.936.9003 Please complete a registration package for each person coming to the camp (both the person with aphasia and any family member or friend). Sea-to-Sky Aphasia Camp 2014 1
FORMS TO KEEP: A. Directions to camp B. Accommodation and Meal Information C. Camper Packing List FORMS TO RETURN: D. Camper Information Form E. Activities checklist F. Health History Form G. Communication Survey H. Technology Survey I. Physical Needs Survey J. Consent/Waiver Form(s) Sea-to-Sky Aphasia Camp 2014 2
A. Directions to camp (keep this form) Camp Squamish is located just outside of Squamish. The camp address is 41015 Government Rd. Directions from Vancouver 1. Follow Highway 99 towards Whistler (North) 2. Follow the Highway past Squamish city 3. Turn LEFT on Garibaldi Way 4. Turn RIGHT on Government Road 5. Camp Squamish is located on the right hand side of Government Road Directions from Whistler 1. Follow Highway 99 towards Vancouver (South) 2. Follow the Highway past Alice Lake Provincial Park 3. Turn RIGHT on Garibaldi Way 4. Turn RIGHT on Government Road 5. Camp Squamish is located on the right hand side of Government Road Sea-to-Sky Aphasia Camp 2014 3
B. Accommodation and Meal Information (keep this form) Accommodations: The camp has two lodges (Nootka and Haida). Each lodge has two floors. There is room for 65 people to sleep in each lodge. The lodges have bathrooms and showers on both floors. The lodges also have lounge with a fireplace and TV/DVD player. All of the rooms and bathrooms on the main floor are wheelchair accessible. Meals: The camp can make special meals for people with specific dietary needs. Breakfast Lunch Dinner 8:30 am 12:00 pm 5:30 pm Sea-to-Sky Aphasia Camp 2014 4
C. Camper Packing List Toiletries Toothbrush & toothpaste Shampoo & Conditioner Soap Hairbrush/Comb Deodorant Sunscreen Washcloth Towel(s) Denture supplies (if applicable) Hygiene products (if applicable) Bug Spray Eye glasses/contact lenses and supplies Clothing T-shirts Swimsuit Long-sleeved shirts Shorts Long pants Underwear Socks Warm sweater/heavy jacket Pajamas, robe & slippers Rain suit Sun hat Sunglasses Shoes: at least one pair suitable for walking/hiking (not sandals or flip flops) Sea-to-Sky Aphasia Camp 2014 5
Identification Health Card Equipment Sleeping Bag or single bed sheets and blankets Pillow Towels; towels for pool Adaptive equipment (cane, wheelchair, feeding aides etc.) Communication book or devices Adapted sport equipment such as golf clubs Water bottle Optional Camera An air mattress or foamy to put on top of bed Reading material (books, magazines) Journal; writing materials Puzzles Flashlight Hiking boots Umbrella Sea-to-Sky Aphasia Camp 2014 6
D. Camper Information Form (mail this form) Please write a ( ) in the correct box: Camper with Aphasia Partner/ Friend/ Caregiver Please write only information about yourself. Please complete a form for each person coming to camp. Name: Gender: Male Female Address: City: Postal Code: Email Address: Phone (day): Phone (night): Date of birth: Health Card number: BC ID/Driver s License Family Doctor s Name Address : Family Doctor s Phone Number: Please write a list of your current medications Emergency Contact Information - Primary Contact Name: Relationship: Full Address (including city and postal code): Phone (day): Phone (night): Sea-to-Sky Aphasia Camp 2014 7
E. Activities Checklist (mail this form) Please write a ( ) beside the activities that you are interested in. Aphasia Camper checklist Partner/ Friend/ Caregiver checklist Archery Yoga Stretching Class Hiking/ nature walks Canoeing Woodworking Arts & Crafts Lawn games Kiting (bring your own kite) Fishing (bring your own fishing rod, tackle and license). Swimming Driving range (bring your golf club) Scavenger Hunt Games tournament Biking (bring your own bike) ipad* / tablet* interest *bring if you want Archery Yoga Stretching Class Hiking/ nature walks Canoeing Woodworking Arts & Crafts Lawn games Kiting (bring your own kite) Fishing (bring your own fishing rod, tackle and license). Swimming Driving range (bring your golf club) Scavenger Hunt Games tournament Biking (bring your own bike) Family sharing session Local farmer s market Local farmer s market Other: Other: Sea-to-Sky Aphasia Camp 2014 8
F. Health History Form (mail this form) 1. Please tell us about any important medical problems or health information. 2. Do you have any allergies? 3. Do you have any food allergies or dietary needs? For example: Are you vegetarian? Do you need your food pureed? Are you diabetic? Please be specific. Dietary issue Severity (anaphylaxis) List food dislikes List food intolerances 4. Have you ever had a seizure? a. How often do you have seizures? b. Do you take medication for seizures? 5. Do you need help with anything written below? Please write a ( ) beside the things you need help with. Personal care/ self-care Lifting and transferring Taking medication Assistance to the bathroom Making choices and decisions Controlling anger You must bring someone to camp to help If you wrote a ( ) beside any of the things written above. 6. Do you have any mobility difficulties? 7. Do you use a wheelchair? Sea-to-Sky Aphasia Camp 2014 9
G. Communication Survey (mail this form) What helps you to communicate? Other: How well do you do with each of these? What else should we know about how you communicate? Sea-to-Sky Aphasia Camp 2014 10
H. Technology Survey (mail this form) Please tell us how we can help you use technology to enjoy the camp. Do you use a communication device? Yes No If Yes, what type of device? Other: Do you have: iphone ipad Mini Other Smartphone Other Tablet ipad Will you bring it to camp? Yes No What do you want to use your communication device to help with? Email Writing Speaking Taking Pictures Reading Other: Games Sea-to-Sky Aphasia Camp 2014
I. Physical Needs Survey part 1 (mail this form) Do you use an assistive device to move around? How far can you walk? If you have a wheelchair, do you need assistance with transfers: Yes Sometimes No Please explain: Do you have difficulty with your balance? Yes Sometimes No Please explain: Sea-to-Sky Aphasia Camp 2014
Do you need help using the bathroom? I need to have a commode or toilet in my room. I can walk to the bathroom. Sea-to-Sky Aphasia Camp 2014
I. Physical Needs Survey part 2 (mail this form) How much do these things change your daily activities? Comments: Sea-to-Sky Aphasia Camp 2014
K. Consent/Waiver Form (mail this form) Release of Liability Inherent Risks I, the undersigned, do hereby acknowledge that the Sea to Sky Aphasia Camp is a completely voluntary overnight weekend program designed to provide outreach, support, and social interaction for anyone interested in or affected by aphasia. I understand that Sea to Sky Aphasia Camp will not be monitoring, evaluating, or providing medical attention or healthcare needs support. Sea to Sky Aphasia Camp is in no position to provide on-site care, nor is camp participation a substitute for participants regular medical and health care needs. My well-being and safety is my responsibility throughout the course of the camp weekend experience. Each camp activity carries inherent risks for campers. These risks may include, but are not limited to, contact during sports (with another person, equipment or property), group separation, slips, falls, burns, transportation accidents (provided or carpooling), and other incidents. Inherent risks may lead to injury or illness including, but not limited to, injuries, illnesses, bodily injury, burns, insect bites, head and back injury or death. Assumption of Risks I have read the inherent risks and will participate in the activities of the camp. I accept that there are inherent risks involved in camp activities and agree to accept those risks. I will seek and receive explanations from the camp of any activities I have concerns with or need clarification. Waiver/ Release of Liability In consideration of the camp activities, I agree that the camp or its employees, volunteers, or directors shall not be held liable for any injuries or damages which may arise out of the course of normal camp activities, including accident and inadvertence. Consent to Release Photograph During your stay at Sea to Sky Aphasia Camp, your photograph, video or audiovisual maybe taken by employees/agents or authorized media (newspaper/radio/television) to make, use, edit, and publish photographs, videotapes, or other audiovisual records of you for the intended purpose of publicity or public relations. Please initial here if you do not wish to have your photograph, video or audiovisual used for promotional purposes. Agreement to Conditions This form must be completed in full. The camp fee must be submitted with this form (if not already sent). Camp fees include accommodation, 3 meals a day, snacks and all activities at camp. Campers requiring any form of assistance (i.e. for purposes of self-care, safety, mobility, behavior, etc.) must be accompanied by an attendant. All campers participating without an attendant must be independent in all aspects of their care. Campers are responsible for bringing all necessary items required for their stay at the camp. Acknowledgement I have reviewed the SEA TO SKY APHASIA CAMP camper information/registration package. I understand and agree to the camp release of liability, consent to release of photographs and Agreement to Conditions. Signature of attendee: Please print name of person signing Date: Sea-to-Sky Aphasia Camp 2014