2023 Camper Application 2023 Camper Application Step 1 of 7 - Camper Background 14% If you require assistance completing any part of the application due to language or accessibility needs, please email director@campcasey.org so appropriate accommodations can be arranged.Please completely fill-out this application to assist us in caring for the camper as safely as possible and so we may ensure the camper has a wonderful week at camp. Near the end of this application, you will have an opportunity to submit medically relevant pictures that you believe would help us care for the camper (eg. AFO and sleep positioning). It is recommended that you prepare these before beginning the application. After submitting this application, you will be contacted by a camper application committee member who will notify you regarding the status of your application. If anything regarding the care of the camper changes between now and the start of camp, please contact your camper application committee member so we can have the most up-to-date information. Will the camper be between the ages of 6 and 17 years old on July 30, 2023?*Due to popularity and accommodations, we have to limit the ages of campers to those between 6 and 17 years old. Yes No Is the camper's disability primarily physical in nature?* Yes No Is the camper able to communicate basic needs and interests to people they do not know, even if it is non-verbally? Please note: volunteers are not all trained with ASL – American Sign Language.* Yes No Does the camper use safe behavior for themselves and others? (We cannot accommodate children who have biting, kicking, punching or physical abusive behaviors. Campers need to stay with the group without one to one assistance. We average a two camper to one counselor ratio.)* Yes No Has the camper been to Camp Casey before?* Yes No We regret to inform you Kiwanis Camp Casey is a one-week summer camp for children ages 6 to 17 years of age who have the following characteristics. 1) Their disability is primarily physical. 2) They can communicate and engage with people they are not familiar and communicate basic needs and interests. Children who are non-verbal but have a clear yes and no and engage with other children at a cooperative play level are appropriate Kiwanis Casey Campers. 3) The camper must use safe behavior both for themselves and others. As an all-volunteer non-profit, we are limited in our ability to provide direct one to one supervision and specialized training for our counselors which we feel the camper would need for a safe overnight camp experience. One reference which may prove helpful in your search for summer camps is the resource listed in the Parentmap Magazine We wish you the very best. If you have further questions, please email the camp director at director@campcasey.org Name:* First Last Name Camper Goes By Gender:* Male Female Non-binary Preferred Pronouns:* she/her he/him they/them Height & Weight:* Feet Inches Weight Date of Birth:* MM slash DD slash YYYY Age when Camp starts (years):* Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent/Guardian (This will be the first Parent/Guardian contacted by the Kiwanis):* First Last Relationship to Camper Parent/Guardian's Email:* Parent/Guardian Primary Phone:* HomeWorkMobileOther Type Phone Parent/Guardian Secondary Phone: HomeWorkMobileOther Type Phone Parent/Guardian: First Last Relationship to Camper Parent/Guardian Primary Phone: HomeWorkMobileOther Type Phone Parent/Guardian Secondary Phone: HomeWorkMobileOther Type Phone Parent/Guardian's Email: Additional Email for Communications: Camper's Email: Do you, as a parent/guardian of the camper, give permission for a member of the Kiwanis Camp Casey Camper Application Committee to contact the applicant's teacher/alternative via email or phone?* Yes No Completion of a teacher questionnaire is required for each new camper applicant. If you have any questions about this process please email or call camp director at: (206) 572-5790 or email at: director@campcasey.orgPlease provide the contact information of the teacher/alternative.* First and Last Name Phone Email Emergency ContactsIn case of emergency where the parents or guardians cannot be reached, please list a contact person. The contact should be able to make decisions and pick-up or make arrangement to pick-up the camper if needed. First Emergency Contact:* First and Last Name Relationship Phone Second Emergency Contact: First and Last Name Relationship Phone Third Emergency Contact: First and Last Name Relationship Phone Medical InformationPlease provide medical contact information for the physician most familiar with the camper's care.Insurance Name, group number, member ID:* Insurance Phone Number:*Physician Information:* Physician Name Physician Phone Primary Disability/Medical Diagnosis:* Resulting Physical Disability:* Resulting Mental Disability:* Does the camper have a school IEP?* Yes No Would you like to upload your camper's IEP, or type out the goals?* Upload Document Type out goals Please upload a copy of your child's IEP here Drop files here or Select files Accepted file types: jpg, gif, png, jpeg, zip, pdf, Max. file size: 100 MB. Please indicate if there are IEP Goals in the following: Physical Self-Help Academic Social Behavior Please Provide Camper's Physical IEP Goals.*Please Provide Camper's Self-Help IEP Goals.*Please Provide Camper's Academic IEP Goals.*Please Provide Camper's Social IEP Goals.*Please Provide Camper's Behavior IEP Goals and Behavior Plans.*In what type of classroom does the camper receive most of their education?* General Ed Resource Room Self Contained (please describe) Other (please describe) Please describe self contained classroom education.*Please describe other classroom education.*Does the camper have any allergies?* Yes No Types of allergies and reactions. (Food dislikes are listed elsewhere.)* Allergies to Medicines Allergies to Foods Other Please describe all allergies and reactions.*Has your camper received the COVID-19 vaccine?*Or will they receive the vaccine by the time camp starts? Yes No My child is not immunized Is the camper up to date on other immunizations?*We strongly encourage campers to be up to date on their immunizations to help prevent the spread of preventable diseases while at camp and in the community. Yes No My child is not immunized Would you consider your child to be immunocompromised?*This information is helpful to allow us to assess the risk of a potential viral infection at camp. Yes No Prefer not to answer We strongly encourage campers to be up to date on their immunizations to help prevent the spread of preventable diseases while at camp and in the community.Does the camper take any medications?* Yes No How many medications does your camper take over a 24 hr period?First medication:* Medication Name Dose (Number only, units entered later) First medication dosage units mg mL mcg grams Pills Units Tabs First Medication Schedule:* Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the first medication.*Second medication: Medication Name Dose (Number only, units entered later) Second medication dosage units mg mL mcg grams Pills Units Tabs Second Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the second medication.*Third medication: Medication Name Dose (Number only, units entered later) Third medication dosage units mg mL mcg grams Pills Units Tabs Third Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the third medication.*Fourth medication: Medication Name Dose (Number only, units entered later) Fourth medication dosage units mg mL mcg grams Pills Units Tabs Fourth Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the fourth medication.*Fifth medication: Medication Name Dose (Number only, units entered later) Fifth medication dosage units mg mL mcg grams Pills Units Tabs Fifth Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the fifth medication.*Sixth medication: Medication Name Dose (Number only, units entered later) Sixth medication dosage units mg mL mcg grams Pills Units Tabs Sixth Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the sixth medication.*Seventh medication: Medication Name Dose (Number only, units entered later) Seventh medication dosage units mg mL mcg grams Pills Units Tabs Seventh Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the seventh medication.*Eighth medication: Medication Name Dose (Number only, units entered later) Eighth medication dosage units mg mL mcg grams Pills Units Tabs Eighth Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the eighth medication.*Ninth medication: Medication Name Dose (Number only, units entered later) Ninth medication dosage units mg mL mcg grams Pills Units Tabs Ninth Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the ninth medication.*Tenth medication: Medication Name Dose (Number only, units entered later) Tenth medication dosage units mg mL mcg grams Pills Units Tabs Tenth Medication Schedule: Breakfast Lunch Dinner Bedtime Other If Other, please specify time belowPlease explain the schedule for the tenth medication.*If you have any additional medication entries, please enter them below by listing the name, dosage and schedule of the medication.Please list any special medication instructions below.Occasionally, campers may need certain over the counter (OTC) medications for minor ailments (headache, allergy, cough & cold, constipation, etc) while at camp. If you permit, our nurses will administer the appropriate OTC medication per their clinical judgement. Please indicate your preferences to allow our nurses to administer OTC medications if they feel it necessary:* Yes, I give permission for my child to receive appropriate OTC medications administered by the nurse. No, do not give any OTC medication without prior consent. Please specify if there are any special instructions for administering OTC medicationsDoes the camper take medications with special foods?* Yes No Please provide special food requirements for medication and provide enough to last the week.* ALL Medications must be given to the nurses at check in before leaving for camp. DO NOT PACK your child’s medications.* I acknowledge I have read the above statement SPECIAL NURSING CARE OR CONCERNSDoes the camper have a VP shunt?* Yes No If yes, describe any special monitoring or care required.* Does the camper have history of seizures or blackouts?* Yes No When was the last occurrence of a seizure or blackout?*Please enter a best guess if exact date is unknown MM slash DD slash YYYY If the camper does have a seizure or blackout at camp, we will contact you immediately. In the event we cannot reach you, please tell us what would warrant a visit to the emergency department.*Has the camper had any recent surgeries that will impact care at camp?* Yes No If yes, describe nature of surgery, including date(s).* Does the camper have open sores or wounds that will require care at camp?* Yes No If yes, describe location and required care (be sure to send PLENTY of wound care supplies).* Is nasal congestion normal for the camper?* Yes No How is this treated at home?* Does the camper have problems with stomach upset?* Yes No If yes, what treatment is used (please send meds used)?* Does the camper have problems with muscle cramps?* Yes No If yes, what treatment is used?* Does the camper have appliances, retainers, contact lenses, glasses, etc. requiring special care?* Yes No Please describe.* Does the camper sunburn easily?* Yes No Our counselors make every effort to keep sunscreen on campers. For best protection, parents might want to consider providing sunhats, clothing, or sun shields for wheelchairs.Have there been any significant changes in family structure or social/emotional issues we should be aware of?* Yes No Please provide a brief detail.* List other concerns, special care required, or helpful hints Eating and Nutritional IssuesPlease indicate how much help the camper needs with eating.* None Partial help needed Total help needed (Please provide detail) Please give detail on the camper's eating needs.*Does the camper have any special diet, food preparation or feeding technique requirements?* Yes No Does the camper have a vegetarian diet?* Yes No Please explain in detail anything you would like us to know about this aspect of the camper's diet.Does the camper have a gluten-free diet?* Yes No Is the camper gluten intolerant or have a gluten allergy? Gluten Intolerant Gluten Allergic Gluten allergy (e.g. Celiac) is characterized by an immune response to gluten consumption.Please explain in detail anything you would like us to know about this aspect of the camper's diet.Does the camper have a blended diet?* Yes No Please explain in detail anything you would like us to know about this aspect of the camper's diet.Please provide any dietary information not covered by the above choices.Does the camper have any extreme food dislikes?* Yes No Please provide more detail.*Does the camper have a feeding tube?* Yes No Please indicate the camper's tube type.* Please indicate the camper's feeding tube formula.* Describe feeding schedule including name, type, amount, and times of supplement. (Be sure and send more than enough cans of food & feeding tube supplies)*Provide the name(s) of other camper(s) the camper would like to eat with. Bladder & Bowel CareIndicate how the camper urinates.* Sit Stand Urinal/leg bag Diapers Catheter (complete section below) What help does the camper need?* Support to sit or stand Emptying, changing,cleaning Transferring Wiping Diapers Changed Bedpan/Urinal None Please explain typical transfer technique in detail.*Please list at-home diaper change schedule.*Please explain bedpan/urinal usage in detail.*Does the camper require urinary catheterization?* Yes No Describe schedule and specifics of bladder/catheterization program or reminder schedule:*Assistance required.* Total Partial Reminder Only None Please elaborate on what assistance is required.*Does the camper require assistance with a bowel program?* Yes No Detailed description of BM schedule.*Does the camper have problems with constipation?* Yes No How is constipation treated at home?*Does the camper have an ostomy?* Yes No Provide type of ostomy and care.**** All campers will be reminded to go to the bathroom or assisted if necessary. Please be sure to send more than enough diapers, undergarments, catheters and ostomy supplies for the week, as well as any other special equipment for your child. We do not have extra supplies. SpeechPlease indicate the camper's speech ability.* No Problem Communication Understandable Non-verbal Please describe in detail how your child communicates a yes and no. How does your child communicate their needs and interests?Special ways used to communicate.* Sign Language Alphabet Board Augmented Communication System None Please only send communication devices that the camper uses independently with success with a variety of people. Please label all equipment. Other information about the camper’s communication (unique phrases or gestures to communicate needs, etc.)Mobility and Special EquiptmentHow will the camper move around at camp?* Walks Manual wheelchair-pushes self Manual wheelchair-needs help Power wheelchair Uses cane Uses walker Other Please explain Other camper mobility needs.* *** We encourage power wheelchair drivers to bring their chairs to maximize independence at camp ONLY if you feel that they are responsible and skilled enough to safely drive with supervision at camp, including driving on uneven terrain, steep inclines, near curbs or in tight spaces with other children. Power wheelchairs can be broken at camp with the rough terrain and unfamiliar ground. Please be aware of this when deciding on the type of chair to send with the camper. Please understand that the Kiwanis cannot be held responsible for broken wheelchairs.Does the camper require help transferring from bed to wheelchair?* Independent Needs stand by supervision/slight physical assist Needs full physical assist Does the camper require help transferring from ground to wheelchair or to stand?* Independent Needs stand by supervision/slight physical assist Needs full physical assist Does the camper require help transferring from wheelchair to toilet?* Independent Needs stand by supervision/slight physical assist Needs full physical assist Does the camper use a shower chair or other adaptations?* Yes No Please elaborate on the equipment the camper uses for showering.*Will you be packing (and labeling!) any specialized shower equipment? (Note: We will provide shower chairs, benches and handheld showerheads at camp.)* Yes No How much assistance does the camper need with sitting without support?* Independent Needs stand by supervision/slight physical assist Needs full physical assist How much assistance does the camper need with changing positions in bed?* Independent Needs stand by supervision/slight physical assist Needs full physical assist Give any other information about the camper's mobility and special equipment needs.AFO/DAFOsDoes your child utilize Ankle Foot Orthosis (AFO/DAFOs)? Yes No When does your child utilize their AFO/DAFOs?When is it appropriate to deviate from this schedule? e.g. If experiencing discomfort, based on level of activity, etc.Please note we will make every effort to follow the most recent AFO schedule your child is usingAre there any additional details about AFOs/DAFOs you would like us to know?Please list all mobility equipment, splints or orthotic equipment the camper will bring to camp. Also, please describe schedule of when equipment should be worn at camp (should be based on most current schedule used during summer). *** Be sure to label everything! Equipment Type (arm splint, dafo, etc.) How/when to be worn.HygieneThere are only showers at camp. We do adapt with hand-held shower heads and have several shower benches.Does your child need any special bath adaptations? Yes No Please describe these bathing proceduresList any special hygiene aides your child will pack.Any additional hygiene details?DressingHow much help does the camper need with dressing?* None (independent) Partial help Total help Which side should be dressed first?* Either Right Left May we wash the camper’s clothes at camp?* Yes No Recommendations**** Even if you do not use laundry services, please label all clothing and equipment with a laundry marker or iron on label. *** Do not bring electronics, such as iPods or handheld consoles. Cell phones will be checked in with the barrack's captain. I have read these recommendations Night CareCan the camper brush his/her own teeth?* Yes No Please explain the camper's oral care procedure.*Is the camper afraid of the dark?* Yes No How is this handled at home?*Has the camper spent a night away from home?* Yes No Does the camper sleep with a special toy?* Yes (Please label and send) No Should the camper be awakened at night to urinate?* Yes No What time at home does the camper go the restroom? Please provide helpful detail.*Are there other details about your child’s bedtime routine that would help the counselors?*Name(s) of friends the camper would like to sleep near. Activities & Other InformationWhat are the camper's main interests and leisure activities?We will be preparing a Camp Casey Directory to include each camper's name, address, phone, and birthday and email address. This directory will only be used by fellow campers, counselors and Kiwanis staff. Please indicate your preference for inclusion in the directory.* Yes, include the camper's information No, do not include the camper's information May we have permission to use photographs of the camper for publicity purposes by the North Central Kiwanis Club or the news media?* Yes No T-shirts*Each camper receives a free Camp Casey T-shirt. Indicate what size the camper needs:Child SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeTraveling to CampKiwanis provide bus transportation from a North Seattle location to and from camp for the convenience of our campers. We will no longer require first-year families to drive their camper to camp. We do not allow parents to visit during the week of camp as it contributes to amplified homesickness for the other campers and causes additional risk management concerns for Kiwanis leadership as we require background checks for all adults spending time at camp. If parents would like to visit camp, we strongly encourage that they drive their child to camp or pick their child up at the end of camp. Campers who are graduating can arrange for family to visit for carnival or the graduation program. Because Kiwanis must finalize the bus transportation contract by June 1st please communicate your final plans by this date. Please answer this question, even if you elect to drive your child to camp. We make every effort to provide safe transportation using chartered buses traveling from north Seattle to camp at Lions Camp Horizons. Please answer the following:Does the camper need to stay in their wheelchair with ADA approved tie downs for best head or trunk control and safety support?* Yes No Can the camper be transferred to standard bus seat and sit next to a counselor?* Yes No Does the camper require a car seat? (If so, please be sure to label and pack it)* Yes No Travel to camp*Drop-off at Camp Casey is free. Our buses leave from and return to 844 NE 78th St in Seattle. If you are planning on bringing the camper directly to camp on Sunday, it is important for us to know so we can plan transportation. Bus - The camper will travel to Camp Casey on the provided bus transportation. Drive - I will arrange to bring the camper directly to Camp Casey between 11:00am and 12:00 noon on Sunday. Bus Drive Name and relationship of person dropping camper off.**** We will be checking identification of those picking up and dropping off campers. Returning from camp*Pick-up at Camp Casey is free. Our buses leave from and return to 844 NE 78th St in Seattle. If someone other than parent or legal guardian will be picking the camper up from camp, they must be designated in emergency contact section of application. Bus - The camper will return from Camp Casey on the provided bus transportation. Drive - I will arrange to pick the camper up at Camp Casey between 7:30am and 9:00am on Sunday. Bus Drive Name and relationship of person picking up camper.**** We will be checking identification of those picking up and dropping off campers. Counselors and nurses want the opportunity to learn your child's name before camp. Please provide a current picture. In addition, add any pictures that would help us provide care for your child. Examples would be splint or bedtime positioning. Drop files here or Select files Accepted file types: jpg, gif, png, jpeg, zip, pdf, Max. file size: 100 MB. Please feel free to provide us with any information you feel will help us care for the camper at camp.In addition, if your application is very complicated or if you have routines or equipment that requires detailed knowledge, please contact us to arrange for a counselor or nurse home visit. We love to hear from our camper's parents! Please read and agree to the forms below.Please read Camp Casey Camper Code of Conduct. (link below)* I have reviewed the Camper Code Of Conduct with the camper. We know what is expected and agree to the guidelines specified. Please read Camp Casey Camper Release form. (link below)* I have reviewed the Camper Release Form with the camper. We know what is expected and agree to the guidelines specified. Legal Acknowledgement:* I have completely and honestly read and filled out the camper application and give permission for the camper to attend Kiwanis Camp Casey. Name of person completing this application:* First Last
