Step 1 of 8 12% Applications must be completed in full (even for returning campers) and accompanied by the $50.00 non-refundable Registration Deposit. 2019 Camp Fees are $50 Registration plus $650 for the Camping Session for a total of $700. Session fees can be paid online using our PayPal link or by check. Completed applications are processed in the sequence received. Session space will not be guaranteed if all required documents & full payment of camp fees are not received by June 1st (unless pre-approved by the Camp Director.)Session ChoiceFirst Choice:Regular Camp - Session One: 7/8 - 7/12Regular Camp - Session Two: 7/15 - 7/19Regular Camp - Session Three: 7/29 - 8/2Regular Camp - Session Four: 8/5 - 8/9Adventure Camp - Session One: 8/12 - 8/16Adventure Camp - Session Two: 8/19 - 8/23Second Choice:Regular Camp - Session One: 7/8 - 7/12Regular Camp - Session Two: 7/15 - 7/19Regular Camp - Session Three: 7/29 - 8/2Regular Camp - Session Four: 8/5 - 8/9Adventure Camp - Session One: 8/12 - 8/16Adventure Camp - Session Two: 8/19 - 8/23Camper InformationCamper's Name* First Middle Last Does your camper have a nickname? Date of Birth:* MM slash DD slash YYYY Gender* Male Female Telephone No.*Email* Camper's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanada Country Check if you have a different mailing address than the address entered above.* Yes, I have a different mailing address No, my mailing address is the same Mailing Address*(if different than above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanada Country Home Phone*Work PhoneCell PhoneName of Group Home (If applicable): Group Home Manager’s Name: Group Home Manager’s Phone:Group Home Manager’s Email: Who should mail be sent to?* Camper Parent/Guardian Other Mail should be sent to(please provide name/address/relationship to camper) Emergency Contact Information(other than those listed above)Contact #1 Name: Contact #1 Relationship: Contact #1 Home Phone:Contact #1 Cell Phone:Contact #2 Name: Contact #2 Relationship: Contact #2 Home Phone:Contact #2 Cell Phone:Will DSHS cover registration fees?* Yes No Provide the Case Manager’s name, email address and telephone number if we are to bill DSHS. Please note $50.00 deposit is required with this application. Personal InformationThe information you provide on the next few pages is critical in assuring your camper’s needs are met and that his/her camp experience will be fun-filled and memorable. If there is anything we should know that isn’t addressed in the following pages, please attach a separate sheet with your comments. Required fields are indicated with an asterick.Primary diagnosis: Secondary diagnosis: Other conditions/concerns: Mobility Walks/runs independently Needs assistance walking/running Needs assistance with steps Uses a cane Uses a manual wheelchair Uses a motorized wheelchair Uses a Gait Belt Wears AFOs or braces on legs Uses a walker Other Other mobilityIf your camper uses a wheelchair, describe transfer procedure and level of assistance required: (If not applicable, please write "N/A")*Is camper prone to slipping and/or falling? No Yes Slipping and/or falling on what types of surfaces? Activity LevelDescribe activity participation Has typical attention span Has short attention span Easily distracted Is hyperactive Will participate in most activities Refuses to participate/prefers to watch Is underactive (needs motivation) Stays with group Wanders away from group You indicated camper wanders, how do you redirect his/her attention?ActivitiesWhat are some favorite activities?Activities your camper does NOT like:Afraid of animals? No Yes What kids of animals is your camper afraid of? Allergic of animals? No Yes What kids of animals is your camper allergic to? What type of allergic reaction? Sensory abilities/sensitivities: Has good fine motor skills Has poor fine motor skills Needs hand over hand Sensitive to loud noises? Uses earmuffs or ear plugs to block noise Sensitive to flashing / twinkling lights or disco ball lights What types of loud noises is your camper sensitive to? If there is additional information we need to know for activity planning, please advise in the box below: (If not applicable, please write “N/A”)*Hygiene and Personal CareUses the toilet on a schedule? Uses the toilet on a schedule? What is the schedule? Uses toilet independently? Uses toilet independently? How do they let you know they need to go? Needs some assistance using the toilet? Needs some assistance using the toilet? Please explain: Does not use toilet at all; uses incontinence briefs (An adequate supply of briefs must be provided for the camper) Does not use toilet at all; uses incontinence briefs (An adequate supply of briefs must be provided for the camper) Requires enemas or suppositories Requires enemas or suppositories Describe bowel schedule: Has a catheter; does camper change independently or is assistance needed? Has a catheter; does camper change independently or is assistance needed? Does camper have a Urostomy Bag? Does camper have a Urostomy Bag? Does camper have a Colostomy Bag? Does camper have a Colostomy Bag? Describe schedule: For female campers:Independent in menstrual care? Is camper independent in menstrual care? If not, and menses will take place during camp session please advise support/assistance needed: (If not applicable, please write “N/A”)* Showering Can shower independently Needs complete assistance in the shower Needs assistance adjusting water Prefers evening shower Needs assistance shampooing Needs assistance soaping Prefers morning shower Needs shower chair or bench Other Please explain: How often does camper shower? Dressing Has no difficulty dressing Can choose own clothes Needs some assistance with dressing Needs total assistance with dressing Can undress partially Needs total assistance undressing Can tie shoes Can work buttons Can work snaps Can manage zippers Can put on belts In the box below describe assistance needed if not addressed above: (If not applicable, please write "N/A")*Sleep Uses CPAP or VPAP Snores Light sleeper Heavy sleeper Needs night light Sleep walks Sings/cries at night Needs bed checks for incontinence Needs bed checks for incontinence if so, when? Should be woken to use toilet Should be woken to use toilet If so, what time? Wakes frequently throughout the night Wakes frequently throughout the night If so, how do you help get your camper back to sleep? Please provide any other information that may be helpful with camper’s night time routine: (If not applicable, please write “N/A”)*Communication Verbal Uses only single words Uses complete sentences Non-verbal Mute Comprehends 2-3 words Comprehends complete sentences Gestures / points to desired items Uses vocalizations Uses PEC boards Uses sign language Understands sign language Uses an AAC device Writes to communicate Please provide any other information that may be helpful: (If not applicable, please write "N/A")* Behaviors Does well in large groups (12 or more individuals) Does well is small groups (fewer than 12) Prefers to be alone Is sensitive to touch Quick to anger (If so, please describe triggers): Aggressive with others. Aggressive with others. If so, please describe triggers: Does camper have a history of self abuse? Does camper have a history of self abuse? If so, please advise stressors: Does camper exhibit obsessive - compulsive behaviors, or any other challenging behaviors? Does camper exhibit obsessive - compulsive behaviors, or any other challenging behaviors? If yes, please explain: What are effective responses to these behaviors?What are effective rewards? What are effective ways to re-direct the camper? Please use the box below to provide additional information that will help us meet your camper’s needs: (If not applicable, please write "N/A")* Dietary Diabetic Sugar free Lactose intolerant Dairy free Gluten free diet Soft diet Vegetarian diet Liquids thickened to the following consistency of Nectar Liquids thickened to the following consistency of Honey Liquids thickened to the following consistency of Pudding Has a good appetite Has a poor appetite Eats excessively Eats fast/needs supervision Needs food cut up Need food blended Difficulty swallowing Takes portions independently Uses special or over-sized utensils (please provide & label with camper’s name) Drinks from cup unassisted Needs straw Needs special cup (please provide & label with camper’s name) Difficulty swallowing Chokes easily Eats through G-Tube (partially) Eats through G-Tube (all food) History of spitting/throwing or grabbing food History of binging History of purging List all foods your camper cannot eat due to severe intolerance and/or allergic reactions:List any ingredients in processed or packaged foods your camper cannot eat due to intolerance and/or allergic reactions:If your camper ingests or comes in contact with any foods or ingredients listed above, describe his/her reaction. Please include physical or behavioral signs/symptoms evidenced and low long after contact symptoms begin:List emergency protocols recommended by your camper’s physician to treat the reaction and reverse the symptoms. (For example Benadryl, Epi-pen, Syrup of Ipepac, etc.):List all foods and/or ingredients in processed or packaged foods that do not cause moderate or severe allergic reactions but may cause physical discomfort, affect mood or behavior:If you have any questions or concerns regarding Food Service and your camper’s dietary needs, please call the Food Services Coordinator at 360-371-0531. Medical Information(to be completed by parent or guardian, not physician)Primary physician: Primary physician Phone:Medical Insurance provider: Medical Insurance policy #: Medicaid number: Primary Diagnosis: Secondary Diagnosis: Drug allergies: Reaction(s):Seasonal allergies: Seasonal allergy Reaction(s):Other allergies (such as bee stings): Other allergy reaction(s):Asthma: COPD: Does camper use an inhaler? Yes No What type? Is assistance required? Does camper use an Epi-Pen? Yes No Is assistance required? Nebulizer? Does camper smoke? Yes No Please note we are a non-smoking facility and accommodations cannot be made for smokers.ImmunizationsAre immunizations current?* Yes No (to be completed by parent or guardian, not physician)Does your camper have seizures? Yes No What type? Frequency? Describe what usually happens prior, during, and after a seizure:Does your camper have: Diabetes High blood pressure Heart problems Fainting spells TBI Back injury Chronic pain Eyeglasses Contacts Hearing Aids Current medications:Please list all prescription medications and over-the-counter medications. Include dosages and frequency:All campers are required to have a physical examination by his/her Physician, Nurse Practitioner or Physician’s Assistant within the six (6) months prior to the start of camp. The Physical Exam Form consists of two (2) pages and must be received by Lions Camp Horizon no later than June 1st. Be sure to make appointments early so you are able to make the deadline. Campers will not be allowed to attend camp without the Physical Exam Form in file. All medications brought to camp must be in blister packs. If blister packs are not available, medications must be in the original containers with the dispensing instructions, date of prescription, and prescribing physician clearly visible on the pharmacy label. We stock most over-the-counter medications (such as Tylenol, Ibuprofen, Benadryl, Pepto Bismol.) Please check with us in advance to see if we have a specific OTC medication your camper may need. We cannot refill prescriptions. You must provide sufficient quantities of prescription medications for five (5) days. Please include a photocopy of your camper’s current medical insurance card or a copy of his/her current medical coupon with this camper application.I hereby give permission to Lions Camp Horizon medical staff to provide routine health care and first aid; to administer the pre-scription medications and/or over-the-counter medications that the camper’s licensed healthcare provider listed on the Physical Examination Form; to release any records necessary for insurance purposes; and to provide or arrange transportation to access medical care deemed necessary for my camper.* Parent/Guardian Initial aboveIn the event I cannot be reached in an emergency, I hereby give permission to the health care provider selected by the LCH staff to administer treatment including x-rays, routine tests, injections, surgery, or hospitalization for:* Camper's Name and Parent/Guardian Initial aboveI hereby release and waive claim, cause, or action which may accrue against LCH, any employee thereof, or any other persons acting with their permission, for any injury that may happen to the camper during his/her stay at LCH or during an activity approved by any of the said persons.* Parent/Guardian Initial aboveData Collection Consent* I consent to my submitted data being collected and stored. View our Privacy Policy for more info Parent/Guardian Signature*
