Form

Promise Camp June 18-21, 2012

Special Needs Week
Personal Information
Last Name*
First Name*
Middle Name*
Sex*

Male Female
Birth Date*
Month Day Year

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*
- Area Code Phone Number
School*
Grade Level*
Family/ Legal Guardian/ Care Provider Information
Parent(s) or Legal Guardian Name*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*
- Area Code Phone Number
E-mail
Care Provider Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
E-mail
Emergency Contact
First Emergency Contact*
Relation*
Home Phone*
- Area Code Phone Number
Work Phone
- Area Code Phone Number
Cell Phone
- Area Code Phone Number
Second Emergency Contact*
Relation*
Home Phone*
- Area Code Phone Number
Work Phone
- Area Code Phone Number
Cell Phone
- Area Code Phone Number
Health Information
Is Camper free from infectious disease or conditions?*

Yes No
Are immunizations up to date?*

Yes No
Date of last tetanus shot*
Insurance Company*
Insurance Policy*
List all medications, both prescribed and over the counter*
List any allergies (bees, peanuts, other)*
Any Dietary needs that we should know about
History of Disability and Present Condition
Primary Medical Diagnosis*
Second Diagnosis (if any)
Describe the Extent of Disability including year of onset and cause (if known)
Personality/Behavior/Socialization

Please us this "key" (1=always, 2=frequently, 3=sometimes, 4=seldom, 5=never) to indicate camper's behavior in the area described be each of the following words/phrases
....*

friendly toward others

enjoys helping others

behaves rudely/inappropriately towards others

shares or cooperates with others

willing to try new things

excessive motor activity

acts without thought of consequences to self or others

inappropriate sexual behavior

easily becomes involved in activities

accepts rules easily; complies with requests

avoids social contact with adults and peers

wanders from group situations

aggression without apparent cause

talks about something that is strange, frightening, or disgusting

behavior puts self or others in danger of injury

focuses attention long enough to enjoy recreational and leisure activities

temper outbursts

seems unhappy or sad

goes along with change in daily routine

participates in large group activity without demanding attention or being disruptive

accepts correction and can be redirected toward more appropriate behavior

Total: 0 / 100
Unusual behaviors or behavior problems we might expect to see and ways to handle them
How does camper respond when away from home?*
Daily Living Activities

In the following section, please check all words/phrases that most accurately describes the camper.
.

Eating
Needs help eating*

Yes No
If Yes, Describe
Food Allergies*

Yes No
If Yes, Specify
Needs a straw for drinking*

Yes No
Special utensils needed*

Yes No
If Yes, Specify
Picky Eater*

Yes No
If Yes, Describe foods they wont eat
Type of Eater*
Needs a Special Diet*

Yes No
If Yes, Describe
Needs restrictions on Camp Store.(Candy/Pop)*

Yes No
If Yes, Specify
.

Mobility
Uses Wheelchair*

Yes No
If Yes, Select one
Needs Help transfering in/out of chair*

Yes No
Can bear weight on legs/feet for an assisted transfer*

Yes No
Uses weight bearing aid(if yes, select one)
Uses Braces, if yes list instructions
Restrictions for walking/running, if so describe
.

Hearing
.

Can't hear at all Uses hearing aid or other device slight hearing problem None of the above
Assistance Needed, Specify
.

Communicative Ability
.*

Restricted to signs Uses combination of signs and words Generally speaks in sentences Understands simple sentences, concepts, stories, and directions Uses Glasses None of the above
Can Read*

Yes No
If yes, what grade level
Can Write*

Yes No
If Yes, what grade level
Has problems with Vision*

Blind Legally Blind Neither
.

Equipment
Wears Helmet*

Yes No
If yes, specify when
Wears body jacket*

Yes No
If yes, specify when
.

Toileting
.*

Totally cares for own needs Needs reminders only Needs help getting on/off the toliet Needs help with clothing Needs help with wiping None of the above
(Females) Needs assistance during period.

Yes No
If Yes, Specify
Has a bowel movement every*

Day 2 Days 3 Days 4 Days
Bowel program regulary includes

Laxative use Suppository Use Enema Use
.

Grooming Needs
....*

Needs help combing hair Needs help brushing teeth Needs help shaving Needs chair/stool in shower None of the above
Needs assistance in shower*

Yes No
If Yes, please specify
Needs help getting dressed*

Yes No
If Yes, please specify
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Sleep/Nighttime Routines
Camper has difficulty sleeping through the night*

Yes No
If yes, instructions to help
Has habits that may disturb others*

Snoring Bad Dreams Sleep Walking Talking None of the above
others*

Has fear of dark Has fear of storms Wets the bed Can NOT sleep in the top bunk level None of the above
Needs special positioning to sleep*

Yes No
If yes, please specify
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Swimming
....*

Not permitted to swim at all Some skills- shallow water only Can swim well for deep water Likes to splash around with feet in water Has a fear of water Can swim with flotation device None of the above
If checked last one, please specify
Questions for the Camper!
Favorite Food*
Favorite Game*
I know a lot about
The thing I most like to do with my friends is
My favorite school or work task is
When I have free time I like:*

Board Games Puzzles Watching Videos Drawing/Coloring Craft Projects Cooking Listening to Music Singing Reading Writing Sports Walking
Seizure Information
Type
Frequency
Duration
Observed Behaviors
Reaction after Seizure
Steps of action by medical personnel
Camper Release

List anyone who can pick up your child
Camper may be release to: (church van, parents or guardians listed on form)*
Consent:

In case if medical emergency or general medical care, I gave consent for medical treatment for the above named camper by authorized personnel. The camp carries secondary insurance. I affirm that by accepting below that all of the information i have given is true and complete I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activities and I authorize The Springs to use my camper's picture or testimony in any promotional material(web, print, or media) MY child may recieve e-mails from the camp.
....*

Accept Decline
If the camp should be aware of any other medical needs, please email the camp at thesprings@gmail.com and let us know. Cost of camp is $250. Send in a $50 deposit to save your spot, balance due on arrival. Arrival is 10am on Monday.
Should be Empty:

Promise Camp June 18-21, 2012

Personal Information

Family/ Legal Guardian/ Care Provider Information

Emergency Contact

Health Information

History of Disability and Present Condition

Personality/Behavior/Socialization

Daily Living Activities

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Questions for the Camper!

Seizure Information

Camper Release