2018 Camper Application 2018 Camper Application Please completely fill-out this application to assist us in caring for your child as safely as possible and so we may ensure your child has a wonderful week at camp. 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 your child 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 your child be between the ages of 6 and 17 years old on July 29, 2018?*Due to the popularity and accommodations, we have to limit the number of camper the those between the ages of 6 and 17 years old.YesNoIs your child's disability primarily physical in nature?*YesNoIs your child 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.*YesNoDoes your child use safe behavior for themselves and others?*YesNoHas your child been to Camp Casey before?*YesNo 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 your child would need for a safe overnight camp experience. You may find other summer resources on the webpage for the Center for Special Children’s Services Summer Camp Directory. We wish you the very best If you have further questions, please email camp director at email@example.com Name* First Last Name Camper Goes By Sex*MaleFemaleHeight & Weight* Feet Inches Weight Date of Birth* Age at Camp (years)*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Parent/Guardian Name(s)*Parent/Guardian Phone (Home)* Number Relationship to camper Parent/Guardian Phone (Work) Number Relationship to camper Parent/Guardian Phone (Mobile) Number Relationship to camper Parent/Guardian Phone (Other) Number Relationship to camper 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?*YesNoName 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. Emergency Contact 1* First and Last Name Relationship Phone Emergency Contact 2 First and Last Name Relationship Phone Emergency Contact 3 First and Last Name Relationship Phone Medical InformationPlease provide medical contact information for the physician most familiar with your child 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*For new applicants only: Does your child have a school IEP?*YesNo (or Returning Camper)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 Social IEP Goals*Please Provide Camper's Behavior IEP Goals and Behavior Plans*What type of classroom does your child receive most of his education?* General Ed Resource Room Self Contained (please describe) Other (please describe) Please describe self contained classroom education*Please describe other classroom education*Does your child have any Allergies?*YesNoTypes of allergies and reactions. (Food dislikes are listed elsewhere.)* Allergies to Medicines Allergies to Foods Other Please describe all allergy and reactions*Is your chiled up to date on 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.YesNoMy child is not immunizedDoes your child take any medications?*YesNo* Medication Name Dose (e.g. mg, ml, units) Medication Schedule* Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Medication Name Dose (e.g. mg, ml, units) Medication Schedule Breakfast Lunch Dinner Bedtime Other Please describe other medication scheduleSpecial Medication InstructionsOccasionally, campers may need certain over the counter (OTC) medications for minor ailments (headache, allergy, cough & cold, constipation, etc) while at camp. 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 medications*You have selected "Yes." The camp nursing staff may give your child over-the-counter medications at camp. Please fill-out the table below with any medications you think your child may need while at camp. Include: the dosage, the frequency of medication administration and the reason your child may need this medication. PLEASE BE AS SPECIFIC. Medications used “when needed” (Tylenol, etc).* Medication Name Dose and Time Reason for Medication Medication Name Dose and Time Reason for Medication Medication Name Dose and Time Reason for Medication Medication Name Dose and Time Reason for Medication Medication Name Dose and Time Reason for Medication Does camper take meds with special foods?*YesNoPlease provide special food requirements for medication and provide enough to last the week.*Does child have VP shunt?*YesNoIf yes, describe any special monitoring or care required.*Does child have history of Seizures or blackouts?*YesNoIf yes, date of last occurrence.* Has child had any recent surgeries that will impact care at camp?*YesNoIf yes, describe nature of surgery, including date(s).*Does child have open sores or wounds that will require care at camp?*YesNoIf yes, describe location and required care (be sure to send PLENTY of wound care supplies).*Is nasal congestion normal for your child?*YesNoHow is this treated at home?*Does child have problems with stomach upset?*YesNoIf yes, what treatment is used (please send meds used)?*Does child have problems with muscle cramps?*YesNoIf yes, what treatment is used?*Does child have appliances, retainers, contact lenses, glasses, etc. requiring special care?*YesNoPlease describe.*Does child sunburn easily?*YesNoHave there been any significant changes in family structure or social/emotional Issues we should be aware of?*YesNoPlease provide a brief detail.*List other concerns, special care required, or helpful hintsEating and Nutritional IssuesPlease indicate how much help your child needs eating.*NonePartial help neededTotal help needed (Please provide detail)Does you child have any special diet, food preparation of feeding technique requirements?*YesNoDescribe any special diet, food preparation or feeding techniques required. (If your child has a gluten intolerance, please indicate here. Your application comittee member will be contacting with more information regarding gluten free-options at camp.)*Does child have any extreme food dislikes?*YesNoPlease list your child's extreme food dislikes.*Does your child have a Feeding Tube?*YesNoTub Type*J-TubeG-TubeOtherDescribe feeding schedule including name, type, amount, and times of supplement. (Be sure and send more than enough cans of food & feeding tube supplies)*Name of camper(s) child would like to eat with.Please give detail on you child's eating needs.*Bladder & Bowel CareIndicate how your child urinates.*SitStandUrinal/leg bagDiapersCatheter (complete section below)What help does your child need?*Support to sit or standEmptying, changing, cleaningTransferringWipingDiapers ChangedBedpan/UrinalNoneDoes your child require urinary catheterization?*YesNoPlease provide more detail on urinary catheterization.*Assistance required.*NursingTotalPartialReminder OnlyNoneDescribe schedule and specifics of bladder/catheterization program or reminder schedule:*Does your child require assistance with a bowel program?*YesNoDetailed description of BM schedule.*Does your child have problems with constipation?*YesNoHow is constipation treated at home?*Does your child have an ostomy?*YesNoProvide 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. SpeechIndicate your child's speech ability.*No Problem CommunicationUnderstandableNon-verbalHas a clear yes/noSpecial ways used to communicate.*Sign LanguageAlphabet BoardAugmented Communication SystemNoneOtherPlease only send communication devices that your child uses independently with success with a variety of people. Please label all equipment. Other information about your child’s communication (unique phrases or gestures to communicate needs, etc.)Mobility and Special EquiptmentHow will your child move around at camp?* Walks Manual wheelchair-pushes self Manual wheelchair-needs help Power wheelchair Uses cane Uses walker Other Please explain Other child 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 your child. Please understand that the Kiwanis cannot be held responsible for broken wheelchairs.Does your child require help transferring from bed to wheelchair?*IndependentNeeds stand by supervision/slight physical assistNeeds full physical assistDoes your child require help transferring from ground to wheelchair or to stand?*IndependentNeeds stand by supervision/slight physical assistNeeds full physical assistDoes your child require help transferring from wheelchair to toilet?*IndependentNeeds stand by supervision/slight physical assistNeeds full physical assistHow much assistance does your child need with sitting without support?*IndependentNeeds stand by supervision/slight physical assistNeeds full physical assistHow much assistance does your child need with changing positions in bed:*IndependentNeeds stand by supervision/slight physical assistNeeds full physical assistGive any other information about your child's mobility and special equipment needs.Please list all mobility equipment, splints or orthotic equipment your child 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.DressingHow much help does your child need with dressing?*None (independent)Partial helpTotal helpWhich side should be dressed first?*EitherRightLeftMay we wash your child’s clothes at camp?*YesNoRecommendations**** 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 I pods. Cell phones will be checked in with the barrack's captain. I have read these recommendationsNight CareCan your child brush his/her own teeth?*YesNoIs your child afraid of the dark?*YesNoHas your child spent a night away from home?*YesNoDoes your child sleep with a special toy?*Yes (Please label and send)NoShould child be awakened at night to urinate?*YesNoWhat time at home does child go the restroom? Please provide helpful detail.”*Name(s) of friends your child would like to sleep near.Activities & Other InformationInterest GroupsWe cannot guarantee, but will make every effort for camper to be able to participate with their top two choices for interest groups. Please choose the top three choices for interest groups with one as camper’s first choice. **Interest Groups** Science and Nature - You do science experiments and take nature walks. Drama and Music - Put on a skit or play a concert. Cooking - Stir up a master piece in the mess hall. Casey Yearbook (photography) - Work with campers throughout the week to photograph various events and assemble a memento of Camp Casey 2017 Arts & Crafts - Get your creative side roaring. Sports - Let's get active. Please do not select the same choice multiple times 1st 2nd 3rd We will be preparing a Camp Casey Directory to include each camper's name, address, phone, and birthday and email address. Please indicate your preference for inclusion in the directory.*Yes, include my child's informationNo, do not include my child's informationMay we have permission to use photographs of your child for publicity purposes by the North Central Kiwanis Club or the news media?*YesNoMay we have permission to allow your child to swim in a heated pool with a trained lifeguard and one counselor with each non-swimmer in the pool?*YesNoPlease state reasons why you child is not allowed to participate in swimming.*T-shirtsEach child receives a free Camp Casey T-shirt. Indicate what size your child 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 driving your child to camp or picking 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 the first of June please communicate your final plans by this date. Please answer this question, even if you elect to drive your child to camp. We will have a “field trip” day to either M-Bar-C Ranch for our younger campers or the Blue Fox Drive-In for our older campers. We usually order buses, one with a lift so older or heavier camper can be lifted onto the bus and then transferred to the bus seat with the wheelchairs placed in a truck that travels with the buses. We need to know the exact number of campers who need ADA approved stay in wheelchair tie down on the bus seating. Please answer the following:Does your child need to stay in their wheelchair with ADA approved tie downs for best head or trunk control and safety support?*YesNoCan your child sit next to a counselor on a bus seat, even if full physical assist is required, to transfer to bus seat?*YesNoTravel 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 your child directly to camp on Sunday, it is important for us to know so we can plan transportation. My child will travel to Camp Casey on the provided bus transportation.I will arrange to bring my child directly to Camp Casey between 11:00am and 12:00 noon on SundayName and relationship of person dropping child 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 child up from camp, they must be designated in emergency contact section of application. My child will travel to Camp Casey on the provided bus transportation.I will arrange to pick my child up at Camp Casey between 7:30am and 9:00am on SundayName and relationship of person picking up child.**** We will be checking identification of those picking up and dropping off campers.Please feel free to provide us with any information you feel will help us care for your child 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!AcknowledgementPlease read and agree to the forms below.Please read Camp Casey Camper Code of Conduct.*I have reviewed the Camper Code Of Conduct with my child. We know what is expected and agree to the guidelines specified.Please read Camp Casey Camper Release form.*I have reviewed the Camper Release Form. We know what is expected and agree to the guidelines specified.Campers ages 6 to 13 will need to complete the M-Bar-C Release form and mail it to the address listed at the end of the formM-Bar-C Release FormLegal Acknowledgement*I have completely and honestly filled out the camper application read and give permission for my child to attend Kiwanis Camp Casey.