The Children’s Aid Society-Overnight Respite Scheduling Guide

OVERNIGHT RESPITE 2012/2013

Part I

Disability:

Birth date: ___________________ Age: _________ Gender: ___________

Parent/Legal Guardian 1: __________________

Address: ___________________________________________________________Apt. #

City:__________________________ State:_______ Zip:______________

Home #: Work # : __ Cell #:__________________

E-mail Address: _______________________________________

Home #: Work # : __ Cell #:_____________________

Address(if different)________________________________________________________________

EMERGENCY CONTACT:

In the event of an emergency, Wagon Road Camp will contact the parent(s) first. If we are unable to

reach the parent your emergency contact will be called. This must be someone other than yourself.
Name:________________________________ Relationship:_________________________
Home #: Work # : __ Cell #:____________________
INSURANCE INFORMATION:

Insurance Carrier & Number___________________________________________ ____

Medicaid: Yes No Medicaid Number _____
Waiver: Yes No Service Coordinator: _______________________________________
Agency:__________________________ Phone:____________________
Child’s Social Security #:___________________________ TABS # ________________________

Referring Agency: Phone:________________________

Child’s Doctor_____________________________________Phone:______________________

Name of School Attending:______________________________ Phone:________________________

A parent or guardian must sign the following consent form. The Photograph, Horsemanship, Swimming,

release may be crossed out if you do not wish it to apply.
ADMISSION:I affirm that I am the parent or guardian of

(child’s name)

and that I authorize The Children’s Aid Society to admit him/her to Wagon Road Camp’s Overnight Respite Program. I grant consent for my child to participate in all camp activities: swimming, horsemanship, sports& athletics, cooking, gardening, drama, music, dance, arts/crafts, group performances, professional guest performances, small group games and activities, ropes course activities, and any other activities such as a camp carnival, camp fire, skits, etc. that are part of the camp program. This authorization applies unless I specifically and in writing request my child not participate in an activity.
LOCAL TRIPS: I grant consent for my child to participate in local trips to playgrounds or parks in Chappaqua and the surrounding town of New Castle (this is the town where Wagon Road Camp is located).
LOST ARTICLES: I understand that The Children’s Aid Society is not responsible for lost articles.
PHOTOGRAPHS: I consent to unrestricted use by The Children’s Aid Society of photographs, sound recordings or motion pictures taken of my child for uses authorized by the Society.

MEDICAL: If during the camping period, the society deems it advisable, I give consent to x-rays,

medical treatment, emergency surgery, and dental care.

(parent/guardian)

(witness—if translation or explaining of consent is necessary)

( ) None

( )Medications Which?_____________________________________________________________

( )Animals Which?_____________________________________________________________

What are the allergic reactions?____________________________________________________________

Has your child ever had a seizure or convulsion? ( ) Yes ( ) No

Does he/she still have them? ( ) Yes ( ) No If yes, how often? ___________________________

How long do they last? ____________________ Does he/she need sleep after? _____________________

What are some characteristics of your child’s seizures?_________________________________________

_____________________________________________________________________________________

2. 
   Medications
   

Do you ever adjust or change the medications? ( ) Yes ( ) No Explain:_______________________

_____________________________________________________________________________________
If you disguise medication, how do you do it? ________________________________________________
_____________________________________________________________________________________

Does your child need encouragement to take the medicine? ( ) Yes ( ) No

3. 
   Communications
   

( ) formal sign language ( ) gestures ( ) other________________________________________

Is his/her speech difficult to understand? _____________________________________________________

What areas of speech are you trying to work on now? ___________________________________________

Does he/she become frustrated often over communication problems? _______________________________

D. Self-Care

Does child get dressed: ( ) on own ( ) with some prompting ( ) lots of urging

( ) some assistance ( ) complete assistance

Can child fasten own: ( ) zipper ( ) buttons ( ) snaps ( ) hooks ( ) shoelaces

What other help does your child need with dressing? _____________________________________________

Does your child need help to undress? ( ) Yes ( ) No How?_________________________________

Does your child recognize own clothes? ( ) Yes ( ) No

Does your child frequently lose clothing? ( ) Yes ( ) No
2012-2013

REMINDER: Please be sure to mark everything your child brings to camp with their full name.

Does child need help to: ( ) brush teeth ( ) wash face ( ) wash hands ( ) comb hair

Does child have to be reminded to do these things? ( ) Always ( ) Sometimes ( ) Never

At home, does child usually bathe in: ( ) shower ( ) tub

Is child afraid of showers?___________________________________________________________

Can your child take him/herself to the bathroom without help? ( ) No ( ) Yes

If yes, what assistance is necessary? _________________________________________________________

Does your child ever wet his/her bed? ( ) Yes ( ) No ( ) Occasionally

If child follows a daily schedule using the toilet, please explain: ___________________________________

Does child use any special signs or words for toileting needs?_________________________________________

Does your child get constipated? ( ) Yes ( ) No ( ) Sometimes

If yes, how do you treat it?

Does your child ever wander away from a group or from adults? ( ) Always ( ) Sometimes ( ) Never

Does child ever get out of bed and wander around in the night? ( ) Yes ( ) No

Will child go far, if not stopped? ( ) Yes ( ) No

Do you think child runs because he/she wants adults to chase him/her? ( ) Yes ( ) No

5. 
   Eating
   

Does your child need assistance with eating? ( ) No ( ) Yes

If yes, what kind of assistance is necessary?__________________________________________________

6. 
   Sleep
   

Does your child generally sleep well? Yes ( ) No ( ) If no, explain__

Is child afraid to sleep alone? Yes ( ) No ( ). Does your child have nightmares? Yes ( ) No ( )

Usual bedtime? Usual wake-up time?

7. 
   Habits
   

Does child have any unusual habits (rocking, biting, etc________________________________________

_____________________________ _____________

Do you wish us to try to discourage these habits at camp? ( ) Yes ( ) No

How have you tried to discourage these habits?________________________________________________

8. 
   Previous Separations:
   

Has your child ever spent the night away from home before? ( ) Yes ( ) No

How long was he/she away?_______________________________________________________________

Has child ever been to a sleep-away camp? ( ) Yes ( ) No

If yes, what camp?_______________________________________________________________________

Did child enjoy it? ( ) Yes ( ) No

What did he/she enjoy most? _______________________________________________________________
What did child dislike?____________________________________________________________________

Were you happy with his/her experience? ( ) Yes ( ) No

2012-2013

1. 
   Behavior Issues
   

Does your child have any behaviors requiring special management (tantrums, inappropriate language or touching,

running away, hitting, biting, etc.)?________________________________________________________

_____________________________________________________________________________________

Does your child have behaviors we should be aware of (obsession with specific items, eating inedible objects, etc.)?

Yes ( ) No ( ) If yes, what are they?_____________________________________________________

__________________________________________________________________

What strategies do you use at home with your child when there are behavioral issues?_______________
____________________________________________________________________________________

10. 
    Siblings (only complete if two or more children will be attending camp)
    

If your child is coming to camp with a brother or sister, do you think they will want to spend a great deal of time

together?_____________________________________________________________________________

_____________________________________________________________________________________
Does one child seem more dependent than the other?___________________________________________

Do you want us to encourage their independence?______________________________________________

**********************************************************

If there is anything else you think is important for us to know about your child, or anything special you’d like us to work

on, please feel free to add your comments below.

The Children’s Aid Society

PO Box 47

Chappaqua, NY 10514

Tel: 914-238-4761

Fax: 914-238-0714

Release of Information 2012-2013

Date:___________________

To Whom It May Concern:

I, __________________________________, grant release to

(Name of Parent or Guardian)

__________________________________________ Phone #____________________

(Name of Institution)

to provide The Children's Aid Society’s Respite Program with copies of all psychological, psycho-
social, psychiatric, educational, anecdotal, medical and other relevant material concerning my child,
_________________________________. I also release all staff from your institution to

(Name of Child)

speak to representatives of The Children's Aid Society’s Respite Program regarding
my child.

_______________________________________ _____________________

(Signature of Parent) (Date)

______________________________________ _____________________

(Signature of Translator, if applicable) (Date)

Note: This release is good for one year from the date of signing

Overnight Respite Ropes Course Information

Over the year we will be involving consumers in ropes course activities. These activities are grouped in three ways:
Games: tag, ball toss games, parachute games, etc.
Low Ropes Challenges: physical challenges that are from 1-2 feet off the ground like the Whale Watch or the low zip line swing. These activities are lead by specially trained staff and organized support campers balance.
For example, the Whale Watch is a group, platform teeter-totter. This apparatus can accommodate 12 adults standing on it. A challenge for the campers would be to stand on the platform with a staff member and try to balance it. Depending on the camper and his or her abilities, there may be 2 or 3 campers with

2 or 3 staff doing the challenge.

High ropes Challenges: activities take place from 3 feet–23 feet off the ground. They involve special harnesses, hardware, and climbing rope to provide a belay system to insure safety. Currently, there are two high ropes elements at Wagon Road Camp: the Climbing Wall; and the Trust Swing.
The Climbing Wall is a traditional climbing structure that requires climbing ability and some concentration. The Trust Swing is a completely accessible activity. A participant is fitted with a full body harness, hooked to a climbing rope that runs through a pulley secured to a cable 30 feet above the ground. At the other end of the rope are 7 people who pull on the rope and lift the participant as high as he or she would like to go, up to 24 feet. Many campers like to stay about 5 feet off the ground and swing back and forth. This gives them an experience of flying. Campers in wheel chairs can be put in the harness while they sit in their chairs and lifted into the air from there. In order to deal with any communication

barriers, we pay close attention to the behavior and expressions of each non-verbal camper to see if

they want to do it, and how high they want to go.
Your signature on page 5 “Consent Agreement” grants Wagon Road Camp permission to involve your child in these activities.

If you wish your child not to participate in these activities, please put that in writing below, sign it, and return this with your application.


Part III Overnight Respite 2012/2013 Medical Page 1/2

Must be filled out by a Physician Date:_____________

*Please note that no child can attend camp without a complete health and Immunization History.
Child’s Name:______________________________________ Male ( ) Female: ( ) Birth Date: ____/_____/_____
Diagnosis: 1)_______________________________________________________________________________

2)_______________________________________________________________________________

Onset of Disability:____________________________________________________________________________
Functional physical status: Ambulatory ( ) Wheelchair ( ) Walker ( ) Cane ( )

Allergies: None known ( ) Type:_______________________________________________________________________________

MEDICATION, INCLUDING PRN SINGLE DOSE TIMES PER DAY__

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________
Other treatment or therapy: No ( ) Yes ( ) Type: (e.g. physiotherapy, postural drainage)

Describe:______________________________________________________________________________________

If a girl, has she menstruated? No ( ) Yes ( ) Menstrual irregularities? No ( ) Yes ( )

Describe:______________________________________________________________________________________

IMMUNIZATION HISTORY (Complete in full with dates)

Tuberculin (PPD): Date:________________Result:______________________

DPT: #1________________#2___________________ #3_______________ #4___________

OPV (Polio) #1________________#2___________________ #3________ _______ #4__________

Hepatitus B #1________________#2___________________ #3________________

HIB: #1________________#2___________________ #3________________

Measles Vaccine: ______________________ Mumps Vaccine: __________________________

Rubella Vaccine: _______________________ Tetanus Booster: __________________________

Varicella ________Booster________

HEALTH HISTORY Dates Dates

Chicken Pox No ( ) Yes ( ) ______________________ Measles: No ( ) Yes ( )

Hepatitis No ( ) Yes ( ) ______________________ Mumps: No ( ) Yes ( ) ___________________

Rheumatic Fever: No ( ) Yes ( ) _____________________ Pneumonia: No ( ) Yes ( ) _____________

Diabetes: No ( ) Yes ( ) ______________________ Frequent Colds: No ( ) Yes ( ) _____________

Epilepsy: No ( ) Yes ( ) ______________________ Frequent Ear

Heart Disease: No ( ) Yes ( ) ______________________ Infections: No ( ) Yes ( ) _____________

Tuberculosis: No ( ) Yes ( ) ______________________

Surgery No ( ) Yes ( ) Type:_________________________________________________
Overnight Respite Medical 2012/2013 Page 2/2

Height: ____________________ B.P.:____________________ Pulse:_________________ Weight:______________

Respiration: _______________________ Urinalysis (dip stick):_________________________ Hgb: ________________________

Eyes: ____________________________________________________________ Lung________________________________________

Glasses: No ( ) Yes ( ) Abdomen_____________________________________

Nose:_________________________________________________________________ Skin: ________________________________________

Teeth: ________________________________________________________________ Extremities: __________________________________

Mucous membranes: _____________________________________________________ Posture (spine): _______________________________

Ears: _________________________________________________________________ GI/GU: ______________________________________

Heart: Murmur No ( ) Yes ( )

Notes on findings:_____________________________________________________________________________________________________

Is special diet recommended? No ( ) Yes ( ) Describe:

EXCEPTIONS

Unless exceptions are noted here we will assume that the child can participate in a full range of typical camp activities (including swimming,

baseball, horseback riding, hiking, etc.)

Exceptions:_________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Other Recommendations:
________________________________________________________________________________________________

FOLLOW-UP AND SIGNATURE

It is important that our medical staff know whom they should contact should consultation or clarification be required.

Are you this child’s regular physician? No ( ) Yes ( )

If not, or if you might not be available, could you suggest the name of the physician we should call?

Physician: ________________________________________________________________________

Address:__________________________________________________________________________

At what hospital or clinic is this child known or referred for emergency service:

Hospital:_________________________________________________Clinic:_______________________________

Child’s Hospital/Case #:____________________________________

Hospital __________________________________________Phone:_______________________________

Address:_____________________________________________________________________________________

I have examined the child herein described and have reviewed his/her health history. It is my opinion that he/she is

physically able to engage in camp activities, except as noted above.

Signature:____________________________________________Date:________________________
Name:(print)__________________________________________Phone:_______________________
Address:

Authorization for Medical Treatment

(Standing Order) 2012-2013

Child’s Name: D/O/B: __/___/___

I, (Physician’s Name) authorize for my patient named above
to receive the following medications/treatments while attending Wagon Road Camp.

Medication/Treatment Approval (Circle yes or No)
For fever/pain: Provide dosage if other than

Manufacturer Recommended

Tylenol Yes No Dos:_________________

Motrin Yes No Dos:_________________
For minor abdominal discomfort:

Pepto-Bismol Yes No Dos:_________________

Mylanta Yes No Dos:_________________

Tums Yes No Dos:_________________

For minor skin injury:

Topical antibiotic ointment Yes No

For constipation:

• 
  Only given for 2 days w/o bowel movement & abdominal discomfort:
  

Milk of Magnesia Yes No Dos:_________________

For allergic reaction:

Calamine lotion Yes No

Benadryl Yes No Dos:_________________

For minor cough:

Cough Syrup Yes No Dos:_________________

For difficulty breathing:

Albuterol per nebulizer Yes No Dos:_________________

Physician’s Signature: Date:___/___/___
Parent’s Signature: Date:___/___/___

NYS Regulations Regarding Medications

NYS Regulations require that in order for Wagon Road Camp to dispense medications to a consumer the following conditions must be met:

1. 
   Only medications for which we have doctor’s orders in the form of notations on a signed medical exam, a signed doctor’s note on letter head or prescription pad must be on file at the camp for medications to be dispensed. This includes any over the counter medications, medicated creams, vitamins, and supplements.
   

2. 
   Doctor’s orders are the standard by which medications are given at Wagon Road. Discrepancies between dosage procedures at home, the medication bottle, and the doctor’s orders are resolved by following the doctor’s orders.
   

3. 
   At the time a consumer is confirmed for a program, the parent or legal guardian is responsible to update any doctor’s orders that have changed the medication regimen by providing a written doctor’s order.
   

4. 
   Medications must be delivered to camp personnel in the prescription bottle which has the consumer’s name, the name of the medication, and the dosage.
   

5. 
   Each medication must have its own prescription bottle.
   

6. 
   Medications delivered in inappropriate containers will not be accepted and may mean that a consumer cannot come to the program.
   

7. 
   Any modification to a medication bottle, such as handwriting or changes to the label make the container invalid and inappropriate for delivering medications. As a result medications in such bottles cannot be accepted.
   

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