2015 CAMPER APPLICATION PACKET

Welcome to the Camp Footprints Family! Our Camp Footprints 2015 dates are as follows: Campers: Sunday June 28th - Saturday July 4th. Please return the ENTIRE camper application, all questions answered, signed and any pertinent medical forms attached by MAY 15th, 2015. Please note:

● Applications will not be reviewed until all portions have been received ● All information will remain confidential ● Return application when complete to: Camp Footprints

Camper Application 16475 Fallen Oak Road Hacienda Heights, CA 91745

While we wish we could accommodate everyone, we are unable to guarantee your child’s spot, as we always have many more applications than spots available. We look at many factors when deciding whom is accepted to come to camp which includes, but is not limited to: ● Age

● Medical Needs (including Behavior Issues) ● Previous experience at Camp Footprints We look at all these things such that we are able to, most importantly, provide a safe, medically sound and fun program for the camper. Once the application has been approved by our Medical Staff, a confirmation email will be sent to you along with additional information such as our suggested packing list, daily themes, directions, arrival time, pick up time and an updated medical/medication form. Upon arrival parents/guardians will check in with the medical staff, meet your child’s counselor, unpack in their cabins, tour the campsite and meet our incredible Camp Footprints staff, team leaders, counselors, fellow campers and families. ACCEPTANCE CONDITIONS Camp Footprints reserves the right to refuse to provide services to any camper when the camp staff determines that the camper cannot be provided adequate care and support by Camp Footprints. Campers who are abusive to self, others or property may not be considered appropriate for acceptance. Campers with a history of aggressive behavior or who display such behaviors while at Camp Footprints may be dismissed immediately. These decisions will be made by the Camp Footprints staff. Should it become necessary for your camper to leave camp, for any reason, parents/guardians will be asked to pick up the camper. Parents/guardians will be contacted in the event of any serious injury or illness requiring more than basic first aid, or in the case of any significant incident or behavior issue. OUR POLICY The Camp Footprints organization has a strict policy to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age or disability.

Thank you for your interest in Living a Life Uncommon.   

  

Camp Footprints­Camper Application 2015 

 

CAMPER APPLICATION CHECKLIST

Camper Name:____________________________________________

 

  FORM

❍ Camper Information

❍ Camper Care Information - 4 pages total

❍ Medical Information

❍ Copy of Immunization card

❍ Copy of Insurance card

❍ Medical/Medication Provider Form (MUST BE SIGNED BY DR/NP/PA)

❍ Authorization/Release Form

❍ Current Photo

❍ Camper Deposit/Fee

 Camper Fee: $450.00 Please enclose a $100.00 minimum deposit w/application. Please note camper free must be paid in full no later than June 1, 2015. Camperships: Partial and full camperships are available for those who may need assistance with the camper fee. Camperships will depend upon need and the amount of funds available. Please contact Annette with requests and further information. Should you have any questions or concerns, please do not hesitate to call or contact Annette. Much Love, Camp Footprints Annette Anguiano Hernandez 626.513.3170 annette@campfootprints.com 

  

Camp Footprints­Camper Application 2015 

 

 2015 Camper Application Today’s Date ___/___/_____

   T­Shirt Size: Youth  S  ❍  M ❍  L ❍ Adult  S ❍  M ❍  L ❍  XL ❍  2XL 

❍ CAMPER INFORMATION Name: Last________________________ First________________________ MI________ Nickname:_________________________  Address: Street_________________________________________ Apt.#_______________ City:______________________________  State:________   Zip:_________   Age: _________ Birth date: ___/___/_____ Male ❍ Female ❍ Height: ___________  Weight: __________  Primary Language: ___________________________ Campers’ means of communication:  Verbal  ❍  Non­verbal  ❍  Sign Language  ❍ ASL  ❍ 

          Electronic Device  ❍­______________________(please bring) Disability (Be Specific): ______________________________________________________________ One­to­One Ratio Requested Yes ❍ No ❍   At what developmental age does your camper function? 5­8yr  ❍  9­12yr  ❍  13­16yr  ❍  17­21yr  ❍ How did you learn of Camp Footprints:________________________________________ Attended overnight camp before? Yes ❍  No ❍ Where?_________________ When?_____________  PARENT/GUARDIAN #1 Name: _______________________________________Relationship:__________________________ Address: Street_________________________________________ Apt.#_______________ City:______________________________  State:________   Zip:_________   Phone: Home # (____)____________Cell #(____)______________Work # (____) _______________ Email:_______________________________________________ PARENT/GUARDIAN #2 Name: _______________________________________Relationship:__________________________ Address: Street_________________________________________ Apt.#_______________ City:______________________________  State:________   Zip:_________   Phone: Home # (____)____________Cell #(____)______________Work # (____) _______________ Email:_______________________________________________ Sibling(s)/Ages_____________________________________________________________________  In the event of an emergency, please list two persons other than a parent/guardian, over the age of 18, who know your child and can take full responsibility should you not be available. PRIMARY EMERGENCY CONTACT Name: _______________________________________Relationship:__________________________ Phone: Home # (____)____________Cell #(____)______________Work # (____) _______________  SECONDARY EMERGENCY CONTACT Name: _______________________________________Relationship:__________________________ 

  

Camp Footprints­Camper Application 2015 

 

Phone: Home # (____)____________Cell #(____)______________Work # (____) _______________  Camper Name:__________________________________ CAMPER CARE INFORMATION Please check all that apply and provide detail.  Use additional paper if necessary.  Answers to these questions will greatly assist our counselors in providing proper care to your camper. Does your camper use any of the following special equipment? Please check below. NOTE: Please bring any of these items that your camper normally uses. Manual Wheelchair ❍ Electric Wheelchair ❍ Walker ❍ Prosthetics ❍ Leg/Body Braces ❍ Other Orthopedic Equip ❍ Respiratory Equip ❍ Catheter Equip ❍ Ostomy Equip ❍ Canes ❍ Hearing Aid ❍ Shower/Toilet Chair ❍

Glasses ❍ Other:____________________________________________________________________________ Please note on any special care requirements or instructions for above listed equipment: __________________________________________________________________________________ Camper Walks:   unaided  ❍  w/assistance  ❍  w/braces/canes/walker  ❍  short distances  ❍ Camper uses wheelchair:  all the time  ❍  sometimes  ❍  for long distances  ❍ Camper:  wheels self  ❍      needs assistance  ❍ Swimming: Yes  ❍   No  ❍  Fear of water:  Yes  ❍   No  ❍  Deep water:  Yes  ❍   No  ❍ Campers ears sensitive to water:  Yes  ❍   No  ❍   Needs floats, etc:  Yes  ❍   No  ❍ Additional information:_______________________________________________________________ Environmental Allergies: ❍  Please explain (Cause/Reaction/Medication):______________________ __________________________________________________________________________________  EATING AND DRINKING Camper: feeds self  ❍  w/fork  ❍ w/spoon  ❍  w/fingers  ❍ 

needs assistance:  total  ❍ partial   ❍­explain:___________________________ Requires: food to be cut up  ❍ finely chopped  ❍ pureed  ❍ 

other  ❍­explain:_______________________________________________________ Drinks w/special cup(please send)  ❍ with a straw  ❍ Restrictions: None  ❍  Vegetarian  ❍  Vegan  ❍   

Dairy Free:  Lactose Intolerant  ❍  OK in baked goods  ❍ Gluten Free: Celiac Disease  ❍  Gluten Intolerance  ❍  Dietary Preference  ❍ 

Other: Has a special diet and/or drink instructions/restrictions  ­explain:_______________ _____________________________________________________________________ _____________________________________________________________________ Food Allergies:  ❍ Please explain(Cause/Reaction/Medication/Cross Contamination) __________________________________________________________________________________________________________________________________________ Food Aversion  ❍­explain:_______________________________________________ Diabetic?  ❍­explain:___________________________________________________ 

  

Camp Footprints­Camper Application 2015 

 

Swallowing difficulty  ❍­explain:__________________________________________  Camper Name:____________________________________ DRESSING 

Independent  ❍  Partial assistance  ❍­explain:________________________________ Total assistance  ❍ 

 

WASHING/BATHING Showering: Independent  ❍  Independent w/prompting  ❍   

Partial assistance  ❍­explain:_____________________________________________ Total assistance  ❍  Special bathing needs ❍­explain__________________________ 

Hygiene: Independent  ❍  Independent w/prompting  ❍   Partial assistance  ❍­explain:_____________________________________________ Total assistance  ❍  Special hygiene needs ❍­explain__________________________ 

 

TOILETING Camper: Independent  ❍  Independent w/prompting  ❍   

Partial assistance  ❍­explain:_____________________________________________ Total assistance  ❍   Has bladder control  ❍    Has bowel control  ❍  Catheter  ❍    Self­caths  ❍    Needs nurse assistance  ❍   Please list catheterization schedule:_________________________________________ Wears diapers/pull ups  ❍    all day  ❍    at bedtime only  ❍ Frequent diarrhea:  No  ❍    Yes  ❍­explain__________________________________ Female campers:  Needs assistance if menstruating  No  ❍    Yes  ❍ Special toileting needs ❍­explain__________________________________________ 

 

SLEEPING Camper: Gets up during the night  ❍­explain________________________________________ 

Uses a nightlight  ❍    Using bathroom during the night  ❍­explain_______________ Bedwetting  ❍    Nightmares  ❍    Sleep walking  ❍   Difficulty falling asleep  ❍ Does not sleep alone  ❍    Bedtime:______________   Wake­up time:_____________ Has sleep apnea monitor  ❍­explain________________________________________ Other comments/suggestions for helping your camper settle at night:______________ _____________________________________________________________________ _____________________________________________________________________ 

 

SEIZURES Camper: Has seizures?    No  ❍    Yes  ❍   If yes, what type?___________________________ 

Frequency_______________  Length________________  Last seizure ___/___/_____ Does anything in particular cause a seizure?__________________________________ Any specific behavior proceed a seizure?____________________________________ Any treatment/special care during or after a seizure occurs?_____________________ 

  

Camp Footprints­Camper Application 2015 

 

_____________________________________________________________________ Camper Name:____________________________________ BEHAVIOR Camper: Have any emotional problems or challenging behavior patterns?  No  ❍    Yes  ❍ If yes­please explain:_________________________________________________________________ __________________________________________________________________________________ Have periods when temper/anger/frustration is exhibited?    No  ❍    Yes  ❍ If yes­please explain:_________________________________________________________________ __________________________________________________________________________________ Are there specific things/situations which spark temper/anger/frustration?   No  ❍    Yes  ❍ If yes­please explain:_________________________________________________________________ __________________________________________________________________________________ What does camper do during outburst?___________________________________________________ Have disruptive/assaultive behaviors (hitting, kicking, biting, throwing,etc.)   No  ❍    Yes  ❍ If yes­please explain:_________________________________________________________________ __________________________________________________________________________________ Please explain techniques you use for behavior management (rewards, timeouts, etc.), if necessary: __________________________________________________________________________________ Have any specific fears, worries or concerns?   No  ❍    Yes  ❍ If yes­please explain:_________________________________________________________________ Methods to relieve/redirect:___________________________________________________________ Have a tendency to wander/not want to participate in group?  No  ❍    Yes  ❍ Please explain best way to redirect towards the group:______________________________________ __________________________________________________________________________________ IMPORTANT­PLEASE NOTE: should camper’s needs/behaviors exceed beyond our staffs ability to safely accommodate all concerned, the camper will be sent home. 

 CAMPER PROFILE Camper: Strengths:_________________________________________________________________________ Special interests/hobbies:_____________________________________________________________ What motivates camper:______________________________________________________________ Attitude about attending camp (hopes, fears, concerns):_____________________________________ __________________________________________________________________________________ Family­any recent changes (move, death/illness, divorce, new sibling):_________________________ __________________________________________________________________________________ Personal­has camper experienced any of the following: Difficulty relating to peers  ❍    Changes at school  ❍    Recent hospitalization  ❍    Illness  ❍ If yes­please explain:_________________________________________________________________ __________________________________________________________________________________ 

  

Camp Footprints­Camper Application 2015 

 

  Camper Name:____________________________________ CAMPER PROFILE (CONTINUED) Has camper been treated for any of the following: Depression  ❍   Suicidal thoughts  ❍    Suicidal Attempts  ❍    Violence  ❍    Anxiety  ❍    Other  ❍ If yes­please explain:_________________________________________________________________ __________________________________________________________________________________ Do you feel any of the above may affect your campers time/experience at camp?  No  ❍    Yes ❍  If yes­please explain:_________________________________________________________________ __________________________________________________________________________________ Does camper have a friend/relative coming to camp? Name:__________________________________ Would you like them to be together or in separate groups?___________________________________ Any concerns between them?  No  ❍    Yes ❍  If yes­please explain:_________________________________________________________________ __________________________________________________________________________________  OPTIONAL­ADDITIONAL INFORMATION We encourage you to provide us with any additional information that will assist us in providing the best care and camp experience for your camper during their week at camp: (Please use the remaining and back side of paper, if needed.)  

                   

  

Camp Footprints­Camper Application 2015 

 

  Camper Name:____________________________________ MEDICAL INFORMATION Primary medical diagnosis:____________________________________________________________ Secondary/additional medical diagnosis/issues (such as asthma, dev delay, hearing loss, etc.):_______ __________________________________________________________________________________ Any hospitalizations, ER visits, surgeries in the last 6 months:________________________________ __________________________________________________________________________________ Any surgeries/procedures planned prior to camp:__________________________________________ Does camper have any of the following: Activity restrictions  ❍  Increase risk for injury  ❍ Known risk for bleeding  ❍ If yes to any of the above­please explain:_________________________________________________ __________________________________________________________________________________ Does camper have any pain? No  ❍    Yes  ❍  If yes, explain how you manage it at home:_________ __________________________________________________________________________________ IMMUNIZATIONS With this application, you MUST include a copy of camper’s immunization record AND fill in the record below. 

DTP/DTap  1.  2.  3.  4.  5. 

Tdap  1.         

Polio (IPV/OPV)  1.  2.  3.  4.   

Hepatitis B  1.  2.  3.     

MMR  1.  2.       

Varicella  1.  2.       

Pneumococcal (PCV­13) 

1.         

INSURANCE With this application, you MUST complete the below information AND include a copy of BOTH sides of your insurance card (and pharmacy card, if applicable). Name of Insurance Company:__________________________________________________________ Name of Parent who Insures Camper:___________________________________________________ Policy # or CIN #______________________  Medicaid # (if applicable)________________________ Insurance Company Address:_________________________  Phone Number:___________________ Prescription Plan (Co, ID#)_________________  If group insurance, specify company____________ PHYSICIAN Primary Physician:_______________________________ Dr. #_______________________________ Dr. email:______________________________________ Dr. after­hours #______________________ 

  

Camp Footprints­Camper Application 2015 

 

Specialty Physician:______________________________ Dr. #_______________________________ Dr. email:______________________________________ Dr. after­hours #______________________ 

CAMPER MEDICAL AND MEDICATION PROVIDER FORM To be completed by health care provider (Physician/Nurse Practitioner/Physician’s Assistant) prior to submission of this application.  Please be as detailed as possible and answer all questions.  DR/NP/PA Signature required.  

Today’s Date____________________ Camper Name_______________________________________  Date of Birth____/____/______  

Primary Diagnosis__________________________________________________________________ Secondary/Additional Diagnosis______________________________________________________  

ALLERGIES: Drug________________________________________________________________ Other allergies (specify):________________________________________________ 

 

MEDICATIONS: List all medications, prescription and over­the­counter.  Attach additional pages if necessary. 

Medication  Dosage  Frequency/time taken  Side Effects/Special Notes 

       

       

       

       

       

       

1. Camper does not take any scheduled medications ❍ 2. Does camper know his/her medication schedule? No  ❍ Yes  ❍ 3. Does camper take medication independently?  No  ❍ Yes  ❍ 4. Camp Footprints Nurses distribute medications at Breakfast (8:30AM), Lunch(12PM), 

Dinner(5:30PM),and Bedtime(8PM).  Can campers medications be given at these times? Yes  ❍    No  ❍   If no, please explain:___________________________________________ ___________________________________________________________________________  

      5.   Does camper have any routine/special request for giving/taking medications (w/certain             foods, juices, etc)?   Yes  ❍    No  ❍   If yes, please explain:___________________________________________ 

___________________________________________________________________________  Please add any additional details that you feel will help us care for your patient while he/she is attending Camp Footprints:__________________________________________________________ 

  

Camp Footprints­Camper Application 2015 

 

__________________________________________________________________________________ Physician Statement:  I have examined_____________________who is physically able to engage in all camp activities. I agree with continuing the above medical regimen while at camp. DR/NP/PA signature____________________________ Print Name_________________________ 

AUTHORIZATION AND RELEASE FORM  Camper Name:____________________________________ SHARING OF INFORMATION I give permission for my child to share address, phone number and social media information with campers and staff. Parent/Guardian Initials__________________  PHOTO/MEDIA RELEASE I give permission to Camp Footprints volunteers/staff to photograph and to use pictures, video, or audio of my child/family members for Camp Footprints music videos, newsletter, advertising, fund­raising activities, camp website, social media sites and other forms of visual display for the purpose of personal keepsake and/or promotion of the Camp Footprints organization.  Parent/Guardian Initials__________________  ASSUMPTION OF LIABILITY FOR DAMAGE TO CAMP SITE PROPERTY I understand that the parent/guardian will be responsible for paying for any damage or destruction of campsite property arising as a direct or indirect result of the actions of my child. Parent/Guardian Initials__________________  ACTIVITY CONSENT I give permission for my child to participate in any and all Camp Footprints activities which include but not limited to daily swimming to be supervised by a licensed lifeguard at all times when campers are present. Parent/Guardian Initials__________________  MEDICATION DISTRIBUTION CONSENT I give permission to the medical staff at Camp Footprints to administer prescribed and over­the­counter medication to my child in accordance with the instructions given by our physician and/or Acetaminophen (Tylenol/Ibuprofen/Motrin) as deemed necessary.  I will immediately report any change in my child’s health or change in medication regimen prior to camp. Parent/Guardian Initials__________________  AUTHORIZATION FOR MEDICAL CARE I hereby grant permission to Director Dr. Miles Masatsugu and the medical staff at Camp Footprints to consent to an emergency medical and/or surgical treatment or diagnosis to be rendered to my child under the general and special supervision and upon the advice of a Physician and Surgeon licensed under the provisions of the California Medicine Practice Act, and an emergency examination, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a Dentist licensed under the Provisions of the California Dental Practice Act.  It is understood that Camp Footprints assumes no liability of any kind or character, financial or otherwise for acting pursuant to the above authorization.    

  

Camp Footprints­Camper Application 2015 

 

I THE PARENT/GUARDIAN OF: (camper’s name)_____________________________________________ FULLY UNDERSTAND AND AGREE TO THE TERMS STATED ABOVE AND AGREE THAT ALL INFORMATION IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE.    Parent/Guardian_______________________________________________ Date______________________________ Parent/Guardian_______________________________________________ Date______________________________   Camper Name:____________________________________  OPTIONAL­ADDITIONAL INFORMATION We encourage you to provide us with any additional information that will assist us in providing the best care and camp experience for your camper during their week at camp: (Please use back side of paper, if needed.)                         

  

Camp Footprints­Camper Application 2015