2014 sn app and med form

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)

Source: http://www.grotonwood.org/wp-content/uploads/2014/01/2014-SN-App-and-Med-Form1.pdf