= 2015 Creating solutions, changing lives. Services for children and adults with disabilities in Southern California Easter Seals Southern California 951.264.4855 (P) 760.406.6048 (F) www.easterseals.com/southerncal Dear Parents and Campers, Easter Seals camp will be held August 2nd through August 8 th at YMCA Camp Oakes in the San Bernardino Mountains. Our theme will explore college life and be called Camp University". You are automatically guaranteed ACCEPTANCE at camp if you complete and return the below documents by April 30, 2015. If the below items are NOT returned before April 30th, you are not automatically guaranteed a spot and we will notify you as we process applications whether we have space to accept you or not. The documents to be completed and returned by April 30 th for a guaranteed spot are: Camp Application Financial Statement (with payment or a campership request) Transportation Form The Medical Form must be completed and returned by July 15, 2015. Please complete the medication section of the 2 page Medical Form and have the doctor confirm those medications or update the list when you have your doctor's appointment. Please list ALL medications, vitamins, supplements, etc. that you will be bringing to camp. Check-in at camp will be delayed if there is a discrepancy between the Application/Medical Form and the items brought to camp. The fee charged to campers is $750. The actual cost per camper is $1,126 but Easter Seals subsidizes $376 per camper by raising donations. If you are able to pay more than $750, we appreciate you doing so. If you have difficulty paying $750, we encourage you to solicit donations and some partial camperships are available. A donation guide and form are enclosed should you need assistance in soliciting donations. Regional Center will not cover the cost of Camp. We thank you for your interest in Easter Seals camp and should you have any questions, please contact me at amanda.showalter@essc.org or 951-264-4855. Sincerely, Amanda Showalter Camp Director
Easter Seals Southern California RESIDENT CAMP APPLICATION Sunday, August 2nd thru Saturday, August 8th 2015 (PLEASE PRINT) Camper s Last Name First Name Nickname Camper s Diagnosis Conserved: Yes No ( ) Home Telephone Camper E-Mail Address E-Mail for official correspondence, if different Street Address City Zip M F Age Birthday Developmental Age Language spoken at home ( ) ( ) ( ) Primary contact Home Phone Work Phone Cell Relationship ( ) ( ) ( ) Secondary contact Home Phone Work Phone Cell Relationship ( ) ( ) ( ) Conservator s Name (if applicable) Home Phone Work Phone Cell/Pager Will parent/guardian/conservator be away from home during the camp week? Yes No If yes, where? Phone # ( ) In an emergency, if parent/guardian/conservator cannot be reached, notify: Name: Phone ( ) Relationship to Camper: Name: Phone ( ) Relationship to Camper: Name: Phone ( ) Relationship to Camper: 1 of 8
Is there any special assistance needed with eating or dressing? If so, please describe: Is there any special assistance needed with toileting? If so, please describe bowel regimen (pattern/frequency/max # of days w/o B.M.; is constipation common?) Have there been any changes to health or general well-being in the past year? If so, please list: If there are any physical conditions, past operations or injuries which should restrict camp activity, please specify: If the camper is in school, works or participates in group activities, please provide details: Does the camper require special night care? Yes No If yes, please specify: Does the camper sleep through the night? Yes No If no, please specify: Does the camper exhibit self-abusive behavior or dangerous tendencies that could result in harm to him/herself or others? Yes No If yes, please specify: Is there anything else that you would like us to know? Is camper taking medication? Yes No If yes, please list all medications (INCLUDING vitamins, supplements, etc.). Please provide a comprehensive list. Breakfast Lunch Dinner Bedtime Drug Name strength/ concentration 2 of 8
Media Consent I give my permission for Easter Seals and anyone connected to Easter Seals to use any descriptions, stories, pictures, photographs, recordings of the person named above or things he or she says or does. Easter Seals may use these materials in print, broadcast, on the Web or any other medium and these may be released to the general public at any time. I give Easter Seals all rights to these materials. All of these materials made by Easter Seals are owned by Easter Seals and may be protected by a copyright. I also understand I will not be compensated in any way for use of the material. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - Consent to Administer Prescription Medication I give permission for the camp nurse to administer the prescribed medications listed on the enclosed physician s form, per the doctor s orders listed on the prescription bottle/container. NOTE: All medications must be provided in original containers with unaltered labels. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - Consent to Administer Over-The-Counter Medication I give permission for the camp nurse to administer over-the-counter medication if the nurse and/or consulting physician deem it necessary. Dosages will be administered according to age/weight per directions on the box/bottle unless a physician directs otherwise. Sample OTC medication and reasons for use below: Pain / fever or inflammation.tylenol/jr., Ibuprofen/Jr. Upset stomach, nausea Pepto Bismol, Tums, Maalox Diarrhea..Immodium AD Constipation Milk of Magnesium Insect / plant, skin irritations.calamine Lotion, Cortaid Minor allergy relief..benadryl/jr., Sudafed Cough / cold symptoms...robitussin, Chloroseptic Spray,Tylenol Cough & Cold/Jr. Motrin Cough & Cold/Jr. or equivalents - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - Authorization for Emergency Treatment In case of medical or dental emergency, I/we understand every effort will be made to contact the parents/guardian/conservator of the individual (if applicable). If parent(s)/guardian(s)/conservator cannot be reached I/we authorize the Easter Seals and its' staff as agent for the undersigned, to obtain and consent to x-ray, examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered to said program participant under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital or by a dentist licensed under the provisions of the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist or at said hospital. I/We understand and agree that Easter Seals has no insurance covering such medical or hospital care. Costs incurred for such treatment shall be mine or my parent(s)/guardian(s)/conservator's sole responsibility. It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment or care being required but is given to provide authority and power on the part of Easter Seals, to give specific consent to any and all such diagnosis, treatment or care which a licensed physician or dentist in the exercise of their best judgment may deem advisable in an emergency. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California, and California State Education Code Section 35330. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - Personal Property The undersigned recognizes that neither Easter Seals nor the YMCA of Greater Long Beach/Camp Oakes can accept responsibility for camper s personal property. To reduce losses, the undersigned has ensured that a list of belongings has been attached to camper s luggage. I CONSENT/AGREE TO ALL OF THE ABOVE. Camper/Parent/Guardian/Conservator Signature Date Print Name If adult camper has a conservator, the conservator must sign all forms where signature is requested. If adult camper is legally responsible for him/herself, camper signs ALL signature lines where signature is requested. 3 of 8
EASTER SEALS SOUTHERN CALIFORNIA FINANCIAL STATEMENT The cost of sending a camper to Camp Oakes is $1,126. Easter Seals subsidizes every camper and the amount you are responsible for paying is $750. If you are unable to pay the full $750, campership funds are available, on a limited basis, for those who qualify based on income guidelines. All campers are encouraged to assist Easter Seals in raising funds by asking friends, neighbors and local businesses for contributions. A donation form is enclosed for campers who are able to raise donations. ======================================================================== Section 1 This section must be completed for all campers. Camper s Name: Check the following that apply: I will pay the full camp fee of $750. Payment is enclosed. I will pay the full camp fee of $750 and make an additional donation of I will need partial campership assistance. (Section 2 must be completed.) No refunds will be made if camper leaves camp because of homesickness, behavior problems or is sent home by the camp nurse. To pay by check, make the check payable to Easter Seals. To pay by credit card, circle one: Visa MasterCard Discover American Express Cardholder s Name (PRINT) Account Number Expiration Date Cardholder s Signature: TOTAL Amount to be charged: ======================================================================== Section 2 If you are requesting partial campership assistance. You will need to put your request in writing. Include your annual household income, the number of people who live in your house and the amount that you are requesting in campership funds. Please note that not all campership requests can be granted. Campership funds will be offered on a first come first served basis and Easter Seals will make every attempt to spread the money available around to as many campers as possible. - Without this information, campership funding cannot be granted. - A minimum payment of $400 is required for all campers receiving campership funding. Please send your written request for a campership with the other forms to Easter Seals via: Scan/email to camp@essc.org (preferred method) Fax to 760-406-6048 Mail to: Easter Seals Southern California, 401 S. Ivy St, 4 of 8
EASTER SEALS SOUTHERN CALIFORNIA Amanda Cell-951.264.4855 TRANSPORTATION Easter Seals can only provide limited bus transportation to those returning campers who have no other means of transportation. The family needs to provide transportation to and from camp if at all possible. The fee for bus transportation is: $80.00 round trip or $40.00 one way. Fee must be paid by July 6, 2015. For campers providing their own transportation, Drop off at camp is at 10:00 am on Sunday, August 2nd. Lunch will be provided. Please pick up from camp on Saturday August 8th between 9:00 a.m. and 9:30 a.m. For those campers taking the bus, Campers needing transportation must meet at Easter Seals Riverside office by 11:30 a.m. on Sunday, August 2nd. More information with regards to the Riverside office location will follow in the coming months. Departure from camp is at 10:00 a.m. on Saturday, August 8, 2015. The approximate arrival time back at the Easter Seals Riverside Office is 12:00 p.m. Breakfast on Saturday is the last meal served at camp. Please complete: I will provide transportation for the camper I will need transportation provided by Easter Seals August 2, 2015 August 8, 2015 If you need transportation provided by Easter Seals, answer the next questions. Does camper use a wheelchair? Yes No If yes, can camper transfer? Yes No If yes, can the wheelchair break down? Yes No If yes, is it electric or manual? Elec Man 5 of 8
EASTER SEALS/ YMCA CAMP OAKES Camper Medical Form 2015 This form must be reviewed and signed by a physician. Return the form to Easter Seals by July 15, 2015. Scan/email to camp@essc.org (preferred method) Fax to 760-406-6048 Mail to: Easter Seals Southern California, 401 S. Ivy St, Camper cannot attend camp without a completed and signed medical form before check-in day. Camper s Name: Medical Diagnosis: Medical History and Restrictions: 1) Has there been any recent exposure to a contagious disease or is the patient a carrier of a contagious disease? YES NO If yes, please explain. 2) How would you assess the applicant s current health? (CIRCLE) GOOD FAIR POOR 3) List any chronic health problems (e.g. asthma, pressure sores, cough, constipation) and treatments of which the medical staff should be aware: 4) Does the applicant have any known allergies? YES NO If yes, please describe. 5) Does the applicant have seizures? YES NO If yes, Current status: (i.e. active, controlled): Type of seizure: How often: 6) Has the applicant been hospitalized or treated in an emergency room recently? YES NO If yes, please explain. 7) Are there any physical conditions, past operations or injuries which should restrict camp activity? YES NO If yes, please explain and list any restricted area. 8) Please list any dietary restrictions. 9) Standing BP As needed medications: List any medications that are taken as needed (i.e. for headaches, heartburn, menstrual cycle) specifying the name of the drug, frequency and the corresponding dosage. *Please bring these medications. Drug Name Strength Dose Frequency 6 of 8
NEW CAMPER APPLICATION Scheduled Medications: (Oral Medications, Vitamins, Supplements: List ALL of the oral medications, vitamins, supplements camper is currently taking on a regular basis.) *Please bring these medications. strength/ Breakfast Lunch Dinner Bedtime Drug Name concentration Example Drug XYZ 1 pill = mg 1 pill NA 2 pills NA Liquid Medication 1 ml = mg 5 ml 5 ml 5 ml NA YES NO Do you give medications at any other times of the day or night? If yes, list medications and times. Please try to adhere to the administration times noted above, unless a medication must be given at a different time for medical necessity. PHYSICIAN S CONSENT AND SIGNATURE When seen by me on this date, the above named applicant was free from any contagious or infectious diseases or conditions and is capable of participating in the summer camp program(s) offered at Easter Seals/ YMCA Camp Oakes Physician Signature: Date: Physician s Name (Please Print): Office Phone: Emergency Phone: Address, City, State, Zip: 7 of 8
Final Check List Please be sure to submit the following forms: 1. Resident Camp Application (pages 1-5) 2. Medical Form (pages 6 & 7) The Medical Form must be completed and signed if you are notified that the camper has been accepted to attend camp. The Medical Form is reviewed and signed by a physician and does not need to be submitted with the other documents. The Medical Form must be returned to Easter Seals by July 15, 2015. TOTAL 5 pages (without Medical Form) TOTAL 7 pages (with Medical Form) Please submit the forms by one of the following methods: Scan/email to camp@essc.org (preferred) Fax to 760-406-6048 Mail to: Easter Seals,, For questions about camp, contact Amanda Showalter at Easter Seals at (951) 264-4855 or amanda.showalter@essc.org. Please note, applications that are not complete will be returned 8 of 8
Spring 2015 Dear Camper, Creating solutions, changing lives. Services for children and adults with disabilities in Southern California Donation Guide Easter Seals Southern California 951-264-4855 (P) 760-406-6048 (F) www.essc.org The fee to attend Easter Seals Camp Oakes is $750. If you qualify for a Campership the minimum cost is $400. Easter Seals understands that this expense may be difficult for some to incur. If this is the case, please consider soliciting donations as a means to cover these costs. In the past, many campers have solicited donations from businesses in their community that they often frequent. Some examples of this are banks, grocery stores, and churches. Many businesses have a Matching Gift Program, where an associate will make a donation and the business will match the money donated. Washington Mutual and Wal-Mart are two such places. My suggestion when asking for a camp donation from area businesses would be to: 1. Visit the store in person. 2. Ask to speak with the store manager or community relations department. 3. Tell them about Camp Oakes 4. Let them know how much camp means to you or how much you would like to attend. 5. Bring pictures of your past camp week, if you have them. 6. Share your favorite camp stories. In addition, many campers have turned to friends and family for donations. Ask an aunt, uncle, cousin, grandparent, your pastor and any close friends to donate $10.00 - $20.00. These small donations will add up quickly. Is your birthday coming up? If so, ask for a donation to camp instead of a birthday present. If you have any questions, or need more suggestions on how to ask for donations, please feel free to call me 951-264-4855 or email me at Amanda.showalter@essc.org I am more than happy to help guide you. Thank you, Amanda Showalter Coordinator of Camp Oakes
NEW CAMPER APPLICATION Easter Seals Southern California Donation Form CAMPER NAME: You Can Help! Please support children and adults with disabilities who cannot afford on their own to go to camp. This very special camp helps them enjoy, learn, grow and be challenged. Please make donations to: Easter Seals Resident Camp Program * Please reference camper s name. Resident Camp Activities: Crafts, boating, fishing, nature, archery, horseback riding, cooking, campfires, talent show, non-denominational chapels, special dinners, dances, and much more. Online Donation Credit card donations can be made at: www.easterseals.com/southerncal When making the donation, please include camper s name you want to support. *If you are sponsoring a specific camper, please list camper name in the memo area of your donation check. *All donations should be clearly marked with your name, so that credit can be correctly applied. Sponsor/Donor Address Amount