2014 SPECIAL NEEDS CAMPER APPLICATION: GROTONWOOD
FOR OFFICE USE ONLYDate Rec’d ___________
IMPORTANT: This application will not be considered if it is returned incomplete, or without the Medical Record and required deposit of $250.00 per session for summer camp or $150.00 per session for weekend camps. NOTE: Holdover weekends are only available to Grotonwood campers attending two consecutive weeks of camp. Campers are limited to 2
consecutive sessions of camp; no more than 4 sessions per summer. CAMPER INFORMATION (Note: This is the address ALL correspondence will be mailed to)PLEASE PRINT NEATLY on ALL PAGES.
Camper’s Name: _______________________________________________________________
Type of Residence:
Phone Number: ______________________________ Email: ___________________________
Address: _____________________________________________________________________
City: ______________________________ State: ________ Zip Code: ____________________
T-Shirt Size
( ) Female!Date of Birth: ______________________ Age: _____
Height: __________ Weight: _______ Social Security #: __________________
CONTACT INFORMATION (During the Year AND While at Camp)
Contact Person #1: __________________________________________ Day Phone: ______________________
Relationship to Camper: ______________________________________ Night Phone: _____________________
If not available, please call:
Contact Person #2: __________________________________________ Day Phone: ______________________
Relationship to Camper: ______________________________________ Night Phone: _____________________
Person/Agency Responsible for Transportation
Name: __________________________________________________ Phone: ____________________________
REGISTRATION INFORMATION: GROTONWOOD
Enclosed is my registration fee ($250 per
Please Register for the Following
(NOTE: At Grotonwood, HOLDOVER weekends are available ONLY to campers attending 2 consecutive weeks of camp.)
Camper is attending session(s) at GROTONWOOD!
__________________________________________________________________________________________ provide:
__________________________________________________________________________________________ Agency Name: ________
__________________________________________________________________________________________ Contact Person: _______
__________________________________________________________________________________________ Phone #: _____________
If possible, camper would like to room with: _______________________________________________________ Amount: $ ____________
I understand that the REGISTRATION Fee is non-refundable, non-transferable; and that fees for campers leaving before the end of the session will be pro-rated and refunded ONLY in the case of illness or injury. Make Check payable to GROTONWOOD. Mail Application, Medical Record & Deposit to: 167 Prescott St., Groton, MA 01450
The following information will allow us to plan appropriate activities that will help insure a positive camp experience. Please be specific in your answers, and use another piece of paper if necessary. Time spent now will save you time later.
Grotonwood is a ministry for children, families, and for adults with special needs. The normal camp ratio of counselors to campers is one to eight (1:8). The camp programs at Grotonwood that deal with special needs adults are based upon a 1:4 staff to camper ratio, and daily activities run from 8:00 a.m. to 9:00 p.m. Activities include: Swimming, boating, crafts, nature hikes, games/recreation, campfires, singing, and possible some day trips for certain groups. Your camper MUST meet the following Minimum Abilities list in order to participate in our programs. If you have questions, call the camp office BEFORE you continue with this application. MINIMUM ABILITIES LIST ALL CAMPERS MUST MEET THE ABILITIES LISTED BELOW. Misrepresentation of the applicant may be cause for dismissal from camp without refund. AFTER READING, PLEASE SIGN BELOW. ATTENDING GROTONWOOD: ! MOBILITY:
Must be able to walk without the assistance of a wheelchair* or walker* (limited cane use may be appropriate). Terrain is rough (hills, rocks, dirt roads and paths, stumps and roots, etc.). *A few of these will be allowed ONLY during our “Low Mobility Week” each summer. ! MEDICAL CONDITIONS: 1. Seizure-controlled (NO MORE than 1 seizure per month). 2. Able to eat most normal adult table food (controlled diabetics acceptable). 3. There is limited space available for those with special dietary needs (ie Chopped or pureed diets; gluten-free, food SELF-HELP SKILLS: 1. Uses toilet appropriately (able to wipe self, and toilet self through the night). A person with consistent issues of
incontinence will NOT be accepted. Rare occasions of incontinence should be explained and we will accept on an individual case-by-case basis. 2. Capable of washing, dressing, and eating independently, with minimal help. 3. WOMEN: have an understanding and awareness of, be able to cope with, and independently provide necessary hygiene SOCIAL SKILLS: 1. Able to communicate needs either verbally or non-verbally. 2. Able to relate appropriately to other campers and leadership in a structured program with a 1:4 staff to camper ratio. 3. Able to function in a program involving swimming, boating, archery, etc. 4. Able to stay within physical boundaries of camp setting with no wandering 5. Free from any self-abusive or aggressive behaviors.
If you have questions, please contact the camp office BEFORE completing this application. If this is the FIRST year your client will be applying to attend a session at Grotonwood, you may want to contact our office to discuss the appropriateness of your client, and how your client will “fit” into the program we offer. Please call the camp office at 978-448-5763 and ask to speak to the Registrar, the Special Needs Coordinator, or the Resident Director. I have read the above, and this camper meets, or exceeds, the listed minimum abilities. Please sign below. _____________________________________________________! ___________________________ Signature of Adult Camper and/or Parent/Guardian/Caregiver! UNDERSTANDING THE CAMPER: Primary Diagnosis: __________________________________ Degree of Mental Retardation: ( ) Mild ( ) Moderate ( ) Severe Physical Disability (Describe) ________________________________________________________________________________________ _______________________________________________________________________________________________________________ Does the camper have: !
( ) Other: ___________________________________________________________
Is the applicant able to participate in the normal pace of activities (i.e. walking, hiking, sports, swimming, etc.) or do exceptions need to be made for a slower pace (most rest, sitting out of some activities, etc.?)!
( ) Little or no rest between activities !
PERSONAL Has camper ever attended Grotonwood?!
( ) No !When? ________________________________________
Has camper ever been away from home before?!
Are problems with homesickness anticipated?!
( ) No If yes, what might be the best way of handling it?
_______________________________________________________________________________________________________________
Activities
Please list any activities NOT mentioned above that the camper especially DISLIKES: ________________________________
Please list any activities NOT mentioned above that the camper especially LIKES: ___________________________________
BEHAVIOR & PEER RELATING: SPEECH:! COMMUNICATION:
Can camper communication wants/needs? ( ) Yes!
Method of communication: ( ) Verbal ( ) Sign Language ( ) Communication
Board ( ) Points, Grunts ( ) Gestures ( ) Other: _______________________
Does camper understand and respond to yes/no questions? ( ) Yes ( ) No
Is camper able to communicate pain? ( ) Yes! ( ) No
Further communication instructions and assistance required: _________________
__________________________________________________________________
__________________________________________________________________
HEARING:!
If camper has partial or total loss, please explain the best way to communicate with
____________________________________________________________________________________________________________________________________
COMMUNICATION AND MEMORY:!
plan? ( ) Yes! ( ) No If “yes,” attach a
Follows Directions ( ) Yes ( ) NoPlease explain any “no’s” or how to best help the camper adjust to the daily
schedule of camp: __________________________________________________
__________________________________________________________________
dealing with behaviors: ______________________________________________
MOBILITY:
Does the camper require assistance in walking? ( ) Yes ( ) No
If yes, does the camper use: ( ) Support from another person ( ) Cane
( ) Walker ( ) Crutches ( ) Other: ___________________________________
Describe gait: ( ) Stable ( ) Walks Slowly ( ) Falls Easily ( ) Unsteady
Does camper use a WHEELCHAIR? ( ) Yes ( ) No ( ) For long distances
(please provide): ( ) Manual ( ) Electric
How does camper transfer to and from wheelchair? ( ) Independently ( ) With
arm support ( ) Pivot ( ) 2-person lift ( ) Hoyer Lift ( ) Other: ___________
Can camper support weight in transferring? ( ) Yes ( ) No
Does camper’s mobility level restrict him/her to the FIRST FLOOR? ( ) Yes ( ) No
would feel helpful in providing the best
If ambulatory, can camper walk up/down stairs unaided? ( ) Yes ( ) No If not,
please explain: ______________________________________________________
ADAPTIVE DEVICES: Please take the time to check off and SEND any of the
adaptive device(s) the camper uses on a regular basis: ( ) None ( ) Helmet
( ) Hearing Aid(s) ( ) AFO’s or night braces ( ) Glasses ( ) Dentures
( ) Prosthesis ( ) Contacts ( ) Other: ________________________________Please provide specific instructions on use and care of adaptive devices. Eating:!Assistance Level: ( ) Totally Independent ( ) Can Feed Self Finger Foods ( ) Needs help (cutting/pouring) !
( ) Other/Explain: ___________________________________________________________________
Is camper’s diet: ( ) Normal ( ) Diabetic ( ) Low-Salt ( ) Low Cholesterol ( ) Low-Fat ( ) Other: __________________________Is camper on a medically-prescribed diet or restrictions? ( ) Yes ( ) No If yes, describe or send sample diet menu:_______________________________________________________________________________________________________________Camper does NOT Eat: ( ) Beef ( ) Seafood ( ) Eggs ( ) Pork ( ) Dairy Products ( ) Other: ______________________________Does camper have difficulty: ( ) Swallowing ( ) Chewing ( ) DrinkingDoes camper REQUIRE: ( ) Special utensils (please bring) ( ) Chopped Food ( ) Blended/Pureed Food ( ) Straw!
( ) Diet Supplement (i.e. Ensure; Please bring) ( ) Other: ________________________________________________________
Does camper have any FOOD ALLERGIES? ( ) Yes ( ) No If yes, describe what they are allergic to: ___________________________________________________________________________________________________________________________________________Reactions to Food Allergy: ( ) Hives ( ) Difficulty Breathing ( ) Anaphylaxis ( ) Other: _____________________________________Further eating instructions: _________________________________________________________________________________________
Sleeping Patterns: ( )Normal ( ) Restless ( ) Hard to Wake ( ) Talks in Sleep ( ) Wanders/ Sleepwalks !
( ) Incontinence ( ) Other: ______________________________________________________________________
On average, how many hours does the camper sleep? ________________________________________________________Does camper need bed rails? ( ) Yes ( ) No! Does the Camper need a nightlight? ( ) Yes ( ) NoDoes camper have any bedtime rituals? ( ) Yes ( ) No Please Describe: ____________________________________________________________________________________________________________________________________________Further Sleeping Instructions: ____________________________________________________________________________
Grooming: Dressing: ( ) Independent ( ) Verbal Prompts ( ) Some Help ( ) Total Help If help is needed, please check off the item(s) the camper needs help with: ( ) Buttons ( ) Shoes ( ) Shoe Laces ( ) Socks ( ) Fasteners ( ) Zippers ( ) Shirt ( ) Pants ( ) Underwear/Bra ( ) Other: ____________________________________________________________________________________________________ Further Dressing Instructions: ____________________________________________________________________________ Showering/Personal Care: ( ) Independent ( ) Verbal Prompts ( ) Some Help ( ) Total Help Does camper need assistance with: ( ) Washing face and hands ( ) Showering ( ) Washing Hair ( ) Washing Back ( ) Brushing Teeth ( ) Combing Hair ( ) Shaving ( ) Menstrual Care ( ) Other: _______________________________ Further Personal Care Instructions: _______________________________________________________________________ Bathroom Use: Does the camper need assistance in the bathroom? ( ) Yes ( ) No Verbal Reminders? ( ) Yes ( ) No Please explain bathroom assistance needed: ________________________________________________________________ Does the camper wear Attends/Briefs during the day? ( ) Yes ( ) No During the night? ( ) Yes ( ) No (Please send plenty. If not, you will be billed for our expense) Is the camper on a bathroom schedule during the day? ( ) Yes ( ) No During the night? ( ) Yes ( ) No Please explain: _______________________________________________________________________________________ Check items camper uses (Please bring these items): ( ) Urinal ( ) Bedpan ( ) Catheter - Type: ___________________ Further bathroom instructions: ___________________________________________________________________________ Waiver & Release This document must be signed by either a parent or legal guardian, if applicable. All references to the camper include the parent or legal guardian. As a condition to participating in the summer camp and weekend programs, the camper agrees to the following: Camper acknowledges that a wide variety of activities will be conducted, including swimming. Camper acknowledges that some of the activities may subject him/her to certain stresses and hazards not all of which can be foreseen. Camper desires and consents to take part in all such activities unless otherwise indicated in writing prior to the summer and weekend camp program. Camper assumes all risks incident to the nature of the activities to be conducted and agrees that Grotonwood, nor any of its representatives shall be held responsible for any damages or injuries to the camper. Camper understands that Grotonwood reserves the right to dismiss any camper from further participation in the program in the event the program staff determine that the camper cannot meet the program eligibility requirements. Supervision and transportation resulting from dismissal are the responsibility of the camper. If a camper is sent home for behavioral reasons, there is NO refund of the camp fees. Refunds are given on a pro-rated basis, if a camper must leave early for medical reasons. Camper understands that Grotonwood and its representatives are not responsible for loss or damage to the personal property and possessions of the camper. Camper is liable for any damage to the property of Grotonwood resulting from the acts of the camper. Camper consents to the use of any film/photographs/video taken during the program, whether for advertising, promotion, and/or publicity purposes by Grotonwood unless otherwise indicated in writing prior to the program. The camper waives all claims of compensation for such use. Permission is granted for camper to attend all program field trips upon notification. Camper represents that all of the information provided on this application, including the health/medical forms, is true and correct and that Grotonwood and its representatives have the right and authority to rely on the information contained therein. Camper further recognizes that Grotonwood and its representatives reserve the right to reject any participant in the event of the failure or refusal of the participant to accurately complete and sign all of the required documents. I have read and fully understand the program details, waiver and release. Signature of Camper 18 yrs. or older_________________________________!Date__________________________________ Signature of Parent/Legal Guardian _________________________________! Date __________________________________ 2014 SPECIAL NEEDS CAMPER MEDICAL RECORD: GROTONWOOD IMPORTANT: This application will not be considered if it is returned incomplete, or without the Application and required deposit. The Parent/Legal Guardian, adult camper or staff member must fill in the following information. The intent of this information is to provide camp health care personnel the background to provide appropriate care. Keep a copy of the completed form for your records. Any changes to this form should be provided to camp health personnel before or upon arrival at camp. Provide complete information so that the camp can be aware of your needs. PLEASE PRINT NEATLY THROUGHOUT. Don’t forget to SIGN THE LAST PAGE! It is REQUIRED! CAMPER INFORMATION (Note: This is the address ALL correspondence will be mailed to) Camper’s Name: _____________________________________________________________________________________
Phone Number: ______________________________ ! !
Email: __________________________________________
Address: ____________________________________________________________________________________________
City: ____________________________________________________ State: ________ Zip Code: ____________________( ) Male!
CONTACT INFORMATION (During the Year AND While at Camp) Contact Person #1: __________________________________________ Day Phone: ______________________
Relationship to Camper: ______________________________________ Night Phone: _____________________
If not available, please call:
Contact Person #2: __________________________________________ Day Phone: ______________________
Relationship to Camper: ______________________________________ Night Phone: _____________________
Person/Agency Responsible for Transportation
Name: __________________________________________________ Phone: ____________________________
INSURANCE INFORMATION Insurance coverage for accidents or illness while participating at Grotonwood is the responsibility of the camper and/or their family. Grotonwood has coverage for any camp-related accidents for which the total of all charges is $250 or less. Situations in excess of $250 are the responsibility of the individual’s own insurance.
Carrier: ___________________________________________ Policy or Group No. ____________________________________________
Medicare No. ______________________________________ Medicaid No. __________________________________________________
Address of Carrier: _____________________________________ City: _____________________ State: _________ Zip: ______________
MEDICAL HEALTH HISTORY Primary Diagnosis: ____________________________________________________________________________________ Degree of Mental Retardation: ( ) None ( ) Mild ( ) Moderate ( ) Severe
Physical Disability (Describe): ___________________________________________________________________________
Does the Camper Have: ( ) Mobility Impairment ( ) Hearing Impairment ( ) Epilepsy ( ) Diabetes ( ) Autism
( ) Cerebral Palsy ( ) Seizure Disorder ( ) Visual Impairment ( ) ADD/ADHD ( ) Other: _______________________
Allergies: Please list any known allergies and the allergic reaction the camper may have:
MEDICATION ALLERGIES: _____________________________________________________________________________
FOOD ALLERGIES: ___________________________________________________________________________________
OTHER ALLERGIES: __________________________________________________________________________________
Diabetes!
Does the camper have a history of Diabetes? ( ) Yes! ( ) No
If YES, how is it controlled? ( ) Insulin Dependent!
( ) Controlled by diet alone (please send a
sample day’s menu). Is blood sugar testing required? ( ) Yes ( ) No (if yes, please remember to send the appropriate equipment and supplies)
Seizures!
Does the camper have a history of seizures? ( ) Yes!
If yes, date of last seizure? ____________________ What type(s) of seizures? ____________________________________
How many in the past six (6) months? ___________ Duration of seizures? ________________________________________
Are there any triggers? _________________________________________________________________________________
Describe behavior before: ______________________________________________________________________________
During: _____________________________________________________________________________________________
And after the seizure: __________________________________________________________________________________
Protocol normally followed: _____________________________________________________________________________
Check if individual is subject to any of the following:
( ) Dizziness/Fainting! ( ) Constipation!
( ) High Blood Pressure ( ) Frequent headache
( ) Back Problems ( ) Joint Problems !( ) Chest pain during/after exercise!
( ) Stay OUT of water! ( ) Wear Ear Plugs when swimming (bring)
Please comment on the above checked items for treatment given: _______________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
Recommendations and Restrictions while at camp:
Any medically-prescribed meal plans or dietary restrictions: _______________________________________________________________________________________________________________________________________________________Does NOT eat:! ( ) Beef ( ) Seafood! ( ) Eggs ( ) Pork!
( ) Other: ______________________________________________________________________________
Please explain any dietary restrictions or ALLERGIES the camper may have: ______________________________________
___________________________________________________________________________________________________
Activity Restrictions:
A wide variety of programs are offered at Grotonwood, including those listed below. Please indicate from which activities the camper should be restricted.
Please list any other activities from which you feel the camper should be RESTRICTED: _____________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
MUST be accurate and up-to-date within the previous 24 months; AND, MUST be signed by the doctor (or attach his/her form)
PHYSICAL EXAMINATION
CAMPER NAME: __________________________ Attending Session(s): ____________________The Physical Examination form MUST BE completed and signed by a LICENSED PHYSICIAN. EXAMINATION COMPLETED BY DOCTOR, within the previous 24 months. DATE OF EXAM: ___________________________________________________
Nervous Sys./Pupil Reaction/Reflexes/Gait/
VACCINATIONS! WHAT IS THE CAMPER’S
Tetanus/Diptheria Booster _____________________________! Normal Blood Pressure: ______________________________Rubella Vaccine: ____________________________________! Normal Pulse: ______________________________________Mumps Vaccine (if born after 1956) ______________________! Normal Temperature: _________________________________Measles Vaccine (if born after 1956) _____________________Date of last TB Mantoux Test: __________________________! What was the result? ( ) Positive!
PROBLEM! PRESENT! EXPLANATION
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
ACTIVITY RESTRICTIONS: List any conditions, operations or known serious injury that may affect activity level: ____________________________________ Are there medical reasons to limit or restrict this camper from participating in the SWIMMING PROGRAM? ( ) Yes ( ) No If yes, please explain: _____________________________________________________________________________________
PLEASE list any other activity restrictions while the individual is participating at camp: _______________________________________________________________________________________________________
Examining Physician’s Name (Print) _______________________________________________Signature: _____________________________________________ Date: _________________
Address: ______________________________________________!Phone: ________________
City/State/Zip Code: ___________________________________________________________
NOTE: In the event of illness or injury occurring after this physical report, a descriptive note written by the caregiver and/or physician MUST be sent prior to the participant’s arrival at camp. MEDICATION RECORD IMPORTANT -- PLEASE READ AND SIGN BELOW, even if you take NO Medications! It is vitally important that all PRESCRIBED MEDICATIONS are brought to camp in their ORIGINAL PACKAGING from the PHARMACY, with the CAMPER’S NAME and DOCTOR’S NAME clearly visible on the label. Campers WILL NOT BE PERMITTED TO STAY if medications are pre-packaged in any type of cassette, baggies, envelopes, etc. While at camp, all medications are administered by the camp nurse, except for prescription creams, shampoos, or oral rinses. For these exceptions, the nurse will oversee the administrations of the medication. I have reviewed this completed Camper Health Form. It is correct and complete, and the camper herein described has permission to engage in all activities except noted. I give permission to the camp nurse and/or physician to administer any necessary first aid should a situation requiring medical attention occur while at camp, and IN CASE OF EMERGENCY, give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery. Grotonwood has accident and sickness insurance (including any ambulance transportation which may be required) for the first $250 of a claim. Amounts over $250 are the responsibility of the individual’s primary insurance. I give permission to the camp nurse to administer prescriptions (as noted below) and over-the-counter medication (PRNs) brought to camp.
SIGNATURE: _______________________________________________DATE: ________________
PLEASE NOTE:** Camp Nurse MUST be notified if the below medications CHANGE between the time application is submitted and the actual camp date. A COPY of the physician prescription along with the detailed and complete written instructions MUST accompany camper upon arrival at camp. ATTACH ADDITIONAL SHEETS AS NECESSARY. THIS CAMPER DOES NOT TAKE ANY MEDICATIONS ON A ROUTINE BASIS, and comes to camp with NO Meds. Sample! !
50 mg Sample! ! ! ! m Sample ! ! Tablet, 2 time!s a day. Crush ! pill r Sample!
PLEASE CHECK ALL THAT APPLY: ( ) Swallows meds. whole! ( ) crush meds. ( ) uses oral syringe (please send) !
( ) Takes with applesauce (please send a supply)
SCREENING RECORD (FOR GROTONWOOD use ONLY)
Novità del c.d. “Decreto IMU” dopo la conversione in Legge Con la pubblicazione sul S.O. n. 73/L alla G.U. 29.10.2013, n. 254 è entrata in vigore, a decorrere dal 30.10.2013, la Legge 28.10.2013, n. 124 di conversione del DL n. 102/2013, c.d. “Decreto IMU”. Nell’iter di conversione il citato Decreto ha subito una serie di interessantti modifiche di seguito illustrate. NOVIT
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