Scheduling Guide The following are the dates of our 2012/2013 Overnight Respite Program. In order to be fair about scheduling consumers, each individual is guaranteed 4 invitations to our programs, but may be invited to more if space allows. The scheduling will be done as follows:
There are 8 programs being offered from October 2012 to August 2013. On the attached form, please number each program from 1 to 8 in order of preference. The number “1” being your first choice and the number “8” being your last choice for a program. DO NOT list each number more than once.
We will try to give each consumer his or her top four choices.
We will schedule campers for the year first come first serve. Siblings will always be kept together, unless there is some extenuating circumstance.
We will contact you about the results of the selection process indicating which programs are confirmed.
Two to three weeks before each program, you will receive a call confirming your child’s participation in that particular program and updating any care information. It is at this point that we learn of cancellations and begin to invite other consumers.
Please send or fax this form back to Wagon Road immediately so we can plan for the upcoming programs. Do not wait until you have completed the application package. FAX 914-238-0714.
Drop Off and Pick Up Information NYC Location: The Frederick Douglass Children’s Center
885 Columbus Avenue (between 103 & 104th)
New York, NY 10025
Phone # 212-865-6337 NYC Drop Off Time: Fridays @ 6pm
(except December 27th @ 9am) NYC Pick Up: 4:45pm @ The Fredrick Douglass Children’s Center
Trains to Fredrick Douglass: 1 or 9 103rd Street @ Broadway: walk 1 block north to 104th St and 2 blocks east
to Columbus Avenue. B or C 103rd Street @ Central Park West: walk 1 block north and two blocks west
to Columbus Avenue.
Drive In Directly to Wagon Road: 7:30pm
(except December 27th @ 10:30am)
Pick Up @ Wagon Road: 2:30pm
The Children’s Aid Society-Overnight Respite
Scheduling Form 2012-2013
Directions: Please indicate your program preference by numbering each program 1-8. The number “1” indicating the program your most want your child to attend and the number “8” indicating the program your are least interested in your child attending. Please use each number only once, and cross out programs you cannot use. Please mail or fax this form back to Wagon Road ASAP.
Child’s Name: Phone #: 6:00pm Friday, October 5 – 4:45pm Monday, Oct.8, 2012 3 day – Columbus Day
Circle One: 1 2 3 4 5 6 7 8 9 6:00pm Friday, Nov. 9 – 4:45pm Monday, Nov. 12, 2012 3 day – Veteran’s Day
Circle One: 1 2 3 4 5 6 7 8 9 9:00am Thursday, Dec. 27 – 4:45pm Sunday, Dec 30, 2012 4 day –Holiday Week
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 #:____________________
Medicaid: Yes NoMedicaid Number _____ Waiver: Yes No Service Coordinator: _______________________________________
Child’s Social Security #:___________________________ TABS # ________________________
Name of School Attending:______________________________ Phone:________________________
Name of School Staff Most Familiar with Child:___________________________________________
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
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.
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
Does your child communicate best through: ( ) complete sentences ( ) phrases ( ) single words
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
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
*Please note that no child can attend camp without a complete health and Immunization History. Child’s Name:______________________________________ Male ( ) Female: ( ) Birth Date: ____/_____/_____
NYS Regulations require that in order for Wagon Road Camp to dispense medications to a consumer the following conditions must be met:
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.
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.
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.
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.
Each medication must have its own prescription bottle.
Medications delivered in inappropriate containers will not be accepted and may mean that a consumer cannot come to the program.
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.