Fill - Free fillable Fie-camp-application-2016 FIE Camp Application 2015.pages PDF form

Registration Form

th

July 24 - 27 , 2016

Admission Criteria:

•

Participant must have a diagnosis of Autism Spectrum Disorder.

•

Participant must be at least thirteen years of age or older.

•

Participant’s behaviors must be manageable within the scope of CSU, Chico

policy and

procedures, and the supervision the Co-participant provides.

•

Participant must be exempt from any extreme health care conditions or needs that cannot

be met by their care provider.

Registration Fee:

•

$400.00 per participant

•

NO FEE for Co-participant OR program-provided day assistant

•

Please call to discuss with directors if your child needs a co-participant or can be

provided with a day assistant

Payment Information:

Please note that registration is limited and spots will be allocated on a first come, first

serve basis. Should all spots be filled, Freedom in Elements Camp will compile a wait list

and families will be notified accordingly. Application is due on June 1, 2016.

Session Information:

• Check In: Sunday, July 24, 3pm

• Check out: Wednesday, July 27, 12pm

Location and Contact Information:

Location will be in Whitney Hall for lodging and Sutter Hall for meals.

A. Josephine Blagrave

(530)898-4298

ablagrave@csuchico.edu

SECTION A: PARTICIPANT’S INFORMATION

Parent/Guardian’s Name:

P

E

articipant Name:

Age:

Address (including Postal Code):

Home Telephone:

Alternate Phone Number (Cell/Business):

-mail:

SECTION B: PARTICIPANT MEDICAL INFORMATION & EMERGENCY

PROCEDURES

Insurance Information

Emergency Contact:

Policy

Holder:

Policy

#:

Medication

Allergies? Y/N

1. Does the participant have any Allergies (food or otherwise)? If so, please describe in detail

below:

2. Does the participant have any dietary concerns or have a special diet? Please describe.

(If the participant has a special diet, they must provide their meals and snacks for the weekend)

3. Are they taking any medication? If so, please list all medications below, including whether or

not these prescriptions will be required to be distributed during camp hours.

t

4. Does the participant have any physical limitations? If yes, please describe the extent to which

hey are limiting and any activities that should be avoided.

5. Please describe any and all other health concerns.

Emergency Contact Person (This person should be reachable in the unlikely event of an illness

or emergency should camp staff not be able to make contact with you.)

Name:

Relation

Phone #

Alternate

Phone

#:

Name:

Relation

Phone #

Alternate

Phone

#:

SECTION C: CAMPER PROFILE

In order to provide effective instructional programming, please answer the following:

1. What leisure activities/hobbies does the participant enjoy and how often they participate in

those activities?

2. On a scale of 1-5 please rate the participant’s interest in the following activities.

(1 being doesn’t enjoy, and 5 being really enjoys)

Does not like

Really Enjoys

a. Acting/theater

1

2

3

4

5

b. Photography

1

2

3

4

5

c. Music

1

2

3

4

5

d. Physical Activity

1

2

3

4

5

e. Working in groups

1

2

3

4

5

f. Arts and Crafts

1

2

3

4

5

3. Describe the communicative functioning level of the participant. Please include strategies and

whether he/she is verbal, non-verbal, exhibits any speech concerns or delays in language.

4. Describe the social functioning. For example: Are they a beginner, intermediate or advanced

level? Please explain in detail below.

5. Describe any environmental triggers of stress

6. Describe any environmental calming activities

7

. Please describe all other behaviors or behavioral needs in detail:

SECTION D: CONFIRMATION

I give permission for the information provided on this application to be discussed between Chico

State University’s Kinesiology Department staff and the program (camp) staff. YES

Signature of Participant or Parent/Guardian Date

Participant T-Shirt Size:

_____ Adult Small

_____ Adult Medium

_____ Adult Large

_____ Adult X-Large

_____ Adult XX-Large

_____ Other (Please specify): ____________________

click to sign

signature

click to edit

Co-Participant Information

A co-participant is someone that will attend the entire camp with the participant. They are

responsible for assisting the camper with any activity of daily living needs, medications or any

other self-care requirements that the participant needs assistance with. The co-participant will

share a dorm room with the participant.

Name:

Age:

Address (including Postal Code):

Home Tele

phone:

Alternate

Phone Number (Cell/Business):

: E-mail

Relation

to Participant:

MEDICAL INFORMATION & EMERGENCY PROCEDURES

Insurance Information

Policy Holder:

Policy

#:

Medication

Allergies? Y/N

1. Do you have any Allergies (food or otherwise)? If so, please describe in detail below:

2. Do you have any dietary concerns? Please describe.

3. Do you have any physical limitations? If yes, please describe the extent to which you are

limited and any activities that should be avoided.

4. Please describe any and all other health concerns.

Emergency Contact Person (This person should be reachable in the unlikely event of an illness or

emergency should camp staff not be able to make contact with you.)

Name:

Relation

Phone #

Alternate

Phone

#:

Name:

Relation

Phone #

Alternate

Phone

#:

Co-Participant T-Shirt Size:

____ Adult Small

____ Adult Medium

____ Adult Large

____ Adult X-Large

____ Adult XX-Large

____ Other (Please specify): _______________________

Please return your completed registration form in person or by mail (with payment) to:

A. Josephine Blagrave

Freedom

CSU Chi

400 Wes

Chico, C

In Elements

co, Kinesiology Department

t First Street

A 95929-0330

(Make checks payable to CSU, Chico Adapted Physical Education Program)

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