EASTER SEAL CAMP KYSOC APPLICATION
Accurate information will help us provide the best care and
experience possible. Please do not hesitate to include
additional information you believe may help. Thank you
for your cooperation.
PART I PLEASE PRINT OR TYPE
CAMPER INFORMATION
NAME:__________________________________________________________________________________________
Last First Middle
ADDRESS:_______________________________________________________________________________________
Street/Rural Route
__________________________________________________________________________
City State Zip Code County
___ PHONE:____________________________________SOC. SEC.# __________________________________________
AGE:__________ DATE OF BIRTH: ____/_____/_______ MALE: __________ FEMALE:___________________
Has the individual ever attended Camp KYSOC? Yes______ No_____ If yes, when:__________________
Check type of living situation:
Residential Facility_________ Nursing Home_________ Private Home__________Other_______________
Residential Facility Name ( if applicable)_______________________________________________________
Facility contact person_________________________________________Phone (_____)______-_________
PARENT GUARDIAN/SPOUSE INFORMATION INDEPENDENT ( check appropriate box)
NAME:__________________________ PHONE: (_____)______-________ (______)______-_______________
Day Evening
ADDRESS:_______________________________________________________________________________________
Street/Rural Route City/State/Zip Code
EMPLOYER:_____________________________________________________________________________________
Street/Rural Route City/State/Zip Code Phone
EMPLOYER:_____________________________________________________________________________________
Street/Rural Route City/State/Zip Code Phone
EMERGENCY INFORMATION
In the event that the parent, guardian or spouse cannot be reached, contact the following individuals:
Name1:___________________________________Phone:________________________________________
Relationship_______________________________ Day Evening
Name2:__________________________________Phone:_________________________________________
Relationship_______________________________ Day Evening
___________________________LIABILITY AND RELEASES__________________________
If my camper’s application is accepted, I agree to the indicated method of payment on the back of this permission statement. My camper has permission to attend Easter Seal Camp Kysoc and also leave the campsite on an occasional overnight trip to nearby points of interest under the supervision of camp staff.
I agree to obtain a physical examination by a LICENSED PHYSICIAN for my camper prior to camp. The cost of this examination shall be my responsibility. I understand the examination form is due fifteen days prior to the date my camper is scheduled to arrive at camp.
I understand the Society carries a limited coverage insurance, the undersigned parent or guardian does hereby release and forever discharge the Society, its agents and employees, including members of the staff, from any and all claim(s) for personal injury to the camper which might occur while the camper is at camp or in the custody or control of the society, its employees, or agents, including the camp staff, and which is not covered by the aforesaid insurance.
On occasions, a photographer may take pictures or video of the campers and adults in this camp program. It is understood that they will be taken under the supervision of the Society representative and care will be taken to assure that the individual or the Society will not be embarrassed by their use. I give permission for such pictures to be taken of my camper and for such pictures to be used in any way the Society, its agents or employees, including the camp staff may deem appropriate.
IN CASE OF MEDICAL EMERGENCY, I understand that every effort will be made to contact parents or guardians of the camper. In the event I cannot be reached, I hereby give my permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my camper as named. *** Please bring all medications in the original prescription container. If the camper does not have the original container written specifically for the camper, he or she will not be able to stay at camp.
Transportation to and from camp is the responsibility of the person.
In your opinion may the camper participate in the swimming, boating and lakefront program? Yes__ No__
Does Camper require earplugs for swimming? Yes_____ No ______
In your opinion may the camper participate in the challenge and climbing program? Yes____ No___
Please see enclosed insert for more information about Challenge course and Aquatics.
*****SIGNATURE__________________________________________ DATE____/____/_____
(Must be signed for camper to attend)
PART II PLEASE PRINT OR TYPE
Name of Camper:_________________________________ Date of Birth____/___/____
Name of person completing form:________________________Relationship_________
PERSONAL HYGIENE____________________________________________________
Camper’s assistance level: No Help______ Some______ All Help________________
Camper needs assistance with: Washing ____ Showering_____ Brushing Teeth_____ Menstrual Care ______ Shaving _
Does camper wear Dentures? Yes ___ No __ Does camper remove dentures at night? Yes__ No__
Additional personal hygiene instructions:_______________________________________________
EATING________________________________________________________________________
Assistance level: No Help____ Some Help _____ All Help ______
Describe assistance level:__________________________________________________________
Normal Appetite: Large____Medium ___ Small ____ Is camper on a special diet? Yes___ No___
If yes describe:__________________________________________________________________
Does camper require: Special Utensils ____ (bring own) Chopped Food_____Blended Food_____
Diet Supplement i.e.: Ensure (bring own)
Food Allergy (describe any reactions):________________________________________________
TOILETING_____________________________________________________________________
Is camper independent in toileting? Yes__No__ Does camper need to be reminded? Yes__ No___
Does camper use bathroom in places other than toilet? Yes_____ No________
Does camper have bladder control during the day/and or night? Yes_______ No _________
Is camper on a toileting schedule? Yes_____ No______ If yes, describe:____________________
Does camper use (check all that apply, MUST BRING OWN):
Diaper size___ Colostomy appliances___ Laxatives: Type_______ When______
Catheter_____ Digital Stimulation____ Bedpan ___ Day_____ Night _______
Intermittent Catheter______ How often______ Commode_____ Day_______ Night________
Enema: Type__________ How often_________ Suppository: Type________ How often________
COMMUNICATION_______________________________________________________________
Can camper communicate wants/needs? Verbally_____________ Nonverbally_______________
Does camper understand and respond to questions? Yes________ No_____________
Methods of communication: Understandable speech________ Communication Board________
Electronic Device___________ Sign Language______________
Further communication instructions:__________________________________________________
DRESSING_____________________________________________________________________
Does camper need help with dressing? No Help_____ Some Help_____ All Help________
Camper needs help with: Buttons____ Shoes____ Shoe laces___ Socks____ Zippers______
Pants____ Glasses____ Fasteners____Contacts___ Hearing aids_____
Further dressing instructions:_______________________________________________________
BEHAVIORAL___________________________________________________________________
Check those behaviors that apply to camper: No unusual behaviors_____ Temper Tantrums_____
Physically aggressive toward others___Sexual Abuse History___Yes___ No __Yells/Screams____
Sexually Acts Out ___ Yes____ No____ Withdrawn/Shy _____ Becomes attached to staff______
Verbally aggressive_____ Attaches self to female/male staff______ Self Injurious____ Kicks_____
Wanders/runs away_____ Puts objects in mouths_____ Bites_______ Sleeping Difficulty_______
Explain any checked behaviors, frequency and method of dealing with behavior:_______________
______________________________________________________________________________
Is camper presently on a behavior modification program? Yes___ No_____ If yes, attach a copy.
Has camper ever been away from home before? Yes_____ No______
Are there problems with homesickness? Yes______ No________
DISABILITY /CONDITION___________________________________________________________________
WRITE “P” FOR PRIMARY DISABILITY, “S” FOR SECONDARY DISABILITY
Physical Disability_____ Developmental Disability______ Other______
_____Cerebral Palsy___ _____Attention Deficit Disorder _____Blind/Vision
_____Multiple Sclerosis _____Downs Syndrome Describe____
_____Rheumatoid Arthritis _____Learning Disability _____Deaf/Hearing
Affected Area_______ _____Mental/Developmentally Challenged Describe____
_____Spina Bifida ____Mild _____Behavior Disorder
_____Spinal Cord/Head Injury ____Moderate Describe____
Describe_____ ____Severe/Profound _____Diabetic
_____Stroke _____Prader Willi Syndrome Insulin Dependent_____
Affected area______ _____Seizure Disorder _____Hepatitis
_____Other Type_________ _____Scoliosis
Describe_______ _____Autism _____Tourett’s Syndrome
Describe______ _____Psychosis Diagnosis
Does camper have seizures? Yes____ No____ If yes, type______________ Frequency_________________
Behavior/Aura prior to seizure:
Length of Seizure:___________________________ Recovery time/behavior____________________
Further disability/condition:___________________________________________________________________
ASSISTIVE TECHNOLOGY/AMBULATIONS/SLEEPING___________________________________________
Does camper use a wheelchair? Yes____ No____
Long Distances______ Electric______ Manual _______ Pushes Self:_____ All_____ Part____
Does camper need assistance in transferring? Yes___ No____ Support weight in transferring Yes___ No___
What are the schedule times out of the wheelchair?________________________________________________
Camper’s preferred bedtime: Awakens at________ Sleeps__________ at night.
Favored sleeping position:____________________________________________________________________
Does camper turn over independently? Yes_____ No_____
Does camper need bed rails? Yes_____ No______
Does camper require assistance in walking? Yes_____ No_____ If yes, does camper use:
Support from another person___ Walker____
Cane______ Crutches____
Does camper use or have the following items?
Helmet_____ Shunt_____ Glasses_____
Glasses____ Prosthesis____ Contacts____ Hearing Aid____
Describe gait:
Stable____ Splints_____
Unsteady____ Braces/night braces____ Falls easily______
Will camper require range of motion exercises while at Camp? Yes_____ No______
If yes, please attach a copy of THE EXERCISES
Does camper use a Hoyer Lift? Yes____ No____ Hospital Bed? Yes____ No____
Is Camper Left Handed______ Right Handed______
What are the Camper’s Hobbies?______________________________________________________________
What are the Camper’s likes/dislikes?___________________________________________________________
Additional Instructions:______________________________________________________________________
_________________________________________________________________________________________
RETURN THIS COMPLETED APPLICATION TO: EASTER SEAL CAMP KYSOC
1902 Easterday Road Carrollton, Ky 41008 Incomplete applications will be not registered.