Conductive Education March Break Camp MODC- Brigadoon Village Application

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1 PLEASE PRINT CLEARLY. PREVIOUS APPLICANTS MUST COMPLETE THE ENTIRE FORM. PLEASE NOTE THAT THE DEADLINE FOR APPLICATIONS IS Friday, January 24, 2015 Early Bird Date: January 9 th Program Information: This 4-night/5-day recreation camp is hosted by March of Dimes Canada on the shores of Aylesford Lake, NS at Brigadoon Village. This camp blends traditional camp activities with therapeutic options, including the opportunity of participating in Conductive Education (CE). CE is a unique educational program that teaches skills and techniques to help overcome the challenges of cerebral palsy and developmental delays and how to apply these strategies to everyday life to become more independent. Parents and care givers who attend will benefit from a social component and respite while their children are at camp. Friends and siblings will get to experience all other camp activities omitting the CE classes. At least one parent/caregiver is required to attend for children under 15 years of age. Parents/caregivers are responsible for their children s care from 8 p.m. 8 a.m. If questions concerning this please contact Brittany. Dates: Saturday, March 14- Wednesday, March 18, (Please note the change in day of the week versus last year) Cost: $650 per child/young adult participant (includes all programs, activities, CE classes, meals, accommodation and HST); $ per parent/caregiver, sibling or friend (includes all programs, activities, meals, accommodation and HST). Section A: Participant Information Participant s First Name: Middle Initial(s): Last Name: Date of Birth (month/day/year):: Gender: Diagnosis: Provincial Health Card #: Address (Apt.#, Street #, Street Name): CE 07/12 Page 1 of 10 CE 2015 Brigadoon MODC March Break Camp

2 City: Postal Code: Home Telephone: ( ) I prefer contact by Yes No Name of Parent/Caregiver attending (required for participants under age 15): Name of sibling or friend attending: Please list any relevant interests that sibling or friend may have which may be useful for us in our planning of the camp: Address: Relationship to participant: Date of Birth (month/day/year): Gender: Emergency Contact Information #1 Name of Emergency Contact Relationship to Participant Phone Numbers: Home: Work: Cell: #2 Name of Emergency Contact Relationship to Participant Phone Numbers: Home: Work: Cell: CE 07/12 Page 2 of 10 CE 2015 Brigadoon MODC March Break Camp

3 Section B: Health Information Health Conditions(s) Information: Medications: Name: Dosage: Timing: Notes: (attach a separate page if more space is required) Please list any allergies and describe their severity (e.g., food, medication, etc.): Do you or your child use an Epi-pen?: Yes No Do you or your child have any special dietary needs / restrictions?: Yes No If yes, what are your or their needs?: Pureed Diabetic Chopped Other (specify): Do you or your child use a G-tube?: Yes No If yes, are you providing your own food?: Yes No Family Doctor s Name and Phone Number: Name: Phone Number: CE 07/12 Page 3 of 10 CE 2015 Brigadoon MODC March Break Camp

4 Section C: Activities of Daily Living Task Total Assistance Required Some Assistance Required No Assistance Required Eating Brushing teeth Washing hands/face Grooming Dressing (upper body) Dressing (lower body) Showering / bathing Toileting Transferring: On and off the toilet In and out of the bathtub In and out of bed In and out of a wheelchair Section D: Care Plan (This section needs to be filled out by participants who will be attending camp without a caregiver) 1)Please list any equipment you use for: EATING SELF CARE MOBILITY OTHER Will you be bringing all required equipment with you? CE 07/12 Page 4 of 10 CE 2015 Brigadoon MODC March Break Camp

5 2) Please list any other information that you feel the conductors and staff should know about your personal care. If you would like to set up a meeting (face to face or over the phone) please call or Brittany at (please use back of sheet if necessary. Registration No: Section E: Social Development Choose one of the options below to describe your or your child s social interactions: no difficulties functioning in social situations need prompting and encouragement when getting involved in new experiences need complete supervision within social situations Choose one of the options below to describe your or your child s decision-making skills: independent (no assistance necessary) need moderate prompting need total assistance Choose one of the options below to describe your or your child s cognitive reasoning skills: clearly understand directions and respond accordingly need some direction and further explanation at times often experience confusion with comprehending minimal tasks March of Dimes Canada is committed to handling any personal information that we may collect concerning you and your family member(s) in a professional, respectful, and lawful manner. March of Dimes Canada collects, uses, and discloses personal information in accordance with this privacy statement and our privacy policy. The personal information about you and your family member(s) is used for the purposes of: i. administering the Recreation program, including processing your application ii. contacting you about the status of your application CE 07/12 Page 5 of 10 CE 2015 Brigadoon MODC March Break Camp

6 iii. obtaining feedback about March of Dimes Canada services you receive iv. providing information about March of Dimes Canada to you and others v. complying with the laws and regulations that require the collection, use and disclosure of personal information in connection with the Recreation program. The personal information collected about you and your family member(s) includes information supplied by you in your application and any additional or updated information which we may collect from you in the future. Section F: Release of Information March of Dimes Canada is pleased to provide you with service. From time to time we are interested in receiving your feedback and would like to send you information to help us better serve you. Our Quality Service policy is to ensure that anyone affiliated with March of Dimes Canada recognizes all internal and external contacts as customers and is committed to delivering Quality Service to each and every one of them. In order to conduct satisfaction surveys or to tell you about other services, we request your permission to contact you. In the future, we may like to contact you for one or more of the reasons listed at the bottom of this letter. This will help us continue to offer you quality service and respect your privacy and personal wishes. Thank you for your assistance. Registration No: Print Name: Signature: Date (mm/dd/yy): I agree that March of Dimes Canada may contact me for the following reasons: (check all that apply) To obtain feedback on services I receive from March of Dimes Canada. To advise me of new information or services that may be of interest to me. To provide me with a volunteer opportunity. To solicit my view on services or policies affecting people with disabilities. CE 07/12 Page 6 of 10 CE 2015 Brigadoon MODC March Break Camp

7 Section G: Conductive Education Program Publicity Release Agreement Re: (name of applicant): I hereby grant to March of Dimes Canada and their assigns, and those acting with their permissions, to produce, use, project and show, and otherwise publish, and copy, distribute, and to make alterations and additions to any photographs, videotapes and sound records produced by March of Dimes Canada, with or without using my name. I acknowledge that all copyright in such photographs, videotapes and sound records is the property of March of Dimes Canada. I hereby release March of Dimes Canada and any person or firms using, projecting or showing any such photographs, videotapes and sound records produced by March of Dimes Canada with my consent, from any and all claims for damages for libel, slander, invasion of the right of privacy, breach or infringement or copyright including moral rights, or any other claim based on the use of said photographs, videotapes and sound records produced by March of Dimes Canada. Print Name: Signature: Date (mm/dd/yy): Print Name of Witness: Signature of Witness: Date (mm/dd/yy): Print Name of March of Dimes Canada Representative: Signature of March of Dimes Canada Representative: Date (mm/dd/yy): Section H: Signature It is vital that we have any and all information necessary to determine an applicant s eligibility to participate in this program. March of Dimes Canada reserves the right to refuse any applicant who has submitted an incomplete of falsified application, and to refuse or send home any holidayer whose behavior and/or medical condition is inappropriate for an integrated selfdirected holiday setting. The undersigned verifies that the information given in this application is complete and accurate to the best of his/her knowledge, and agrees to notify Ontario March of Dimes immediately of any change that may affect the applicant s eligibility for the program. Signature of Applicant/Substitute Decision Maker: Date: CE 07/12 Page 7 of 10 CE 2015 Brigadoon MODC March Break Camp

8 Section I: Authorization for Self Medication Assistance and Medical Plan I agree that the staff of March of Dimes Canada (MODC) have my permission to assist me or my child with medication(s) as directed to them. I acknowledge that the staff are not trained professionals and that they have no formal training in the administration of medication, and that they are thereby limited in the assistance that they are able to provide. I understand that it is my responsibility to safely direct the medication procedure(s). I understand that staff are required to maintain a written record of the medication(s) and the assistance that they provide to me or my child. I do hereby release March of Dimes Canada and its employees and agents from all manner of actions, causes of action, suits, losses, damages or injuries, however caused, during or arising from the administration or failure to administer medication as provided herein. I also do hereby agree to indemnify March of Dimes Canada and its employees or agents for any losses or damages sustained by them as a result of such actions or proceedings being commenced against them by myself or my representatives. I, the Consumer, do hereby acknowledge that I have read and fully understand the above terms regarding selfmedication assistance. Note: Please note that MODC staff may only provide dosage as per prescription, or as outlined on the package of over the counter medications, unless doctor-approved dosage change is obtained. All medications must be in either: The original labeled prescription or container; or Blister-Pak prepared by a pharmacy; or A dosette filled by a Regulated Health Care professional I agree to the above terms and references, and agree to abide by the parameters of my approved medication plan. In the event that the participant is only able to provide verbal consent, the signature of a witness is required. The Witness, when required, acknowledges that the participant has confirmed that the March of Dimes Canada employee has explained each clause of this document to him or her and that the participant appears to have fully understood this document. This form may be signed by either the participant or his/her Substitute Decision Maker (SDM). Where there is a signature of an SDM, March of Dimes Canada must have documentation validating status as a Substitute Decision Maker on file. Signature of Participant/Substitute Decision Maker: Print Name (First and Last): Date (mm/dd/yy): Signature of Witness (if applicable): Print Name (First and Last): Date (mm/dd/yy): Signature of MODC designate: Print Name (First and Last): Date (mm/dd/yy): CE 07/12 Page 8 of 10 CE 2015 Brigadoon MODC March Break Camp

9 Section J: Conductive Education Release Form In consideration of March of Dimes Canada assisting to obtain the use of facilities and instruction in order to conduct a program of activity, I/we hereby release and hold harmless March of Dimes Canada, the owners and/ or the operators of the facilities and providers of instruction, the agents and employees of any of these, from all liability and claims for injuries and accidents to the undersigned, as well as loss from any cause of his/her personal property that may occur while participating in or observing the said program of activity. Participant s Name please print): Signature: Name of Witness (please print): Signature: Name of parents or Guardian (please print): Signature: Date mm/dd/yy): Please return this application before Friday, January 24th, 2015 to: Conductive Education March of Dimes Canada 7071 Bayers Road, Suite 153, Halifax, NS, B3L 2C2 Tel: Fax: CE 07/12 Page 9 of 10 CE 2015 Brigadoon MODC March Break Camp

10 Section K: Payment Information Payment of the program fee is required upon application to the program. Your payment will be returned if we are not able to accept you into the camp and will not be cashed/banked until we confirm with you. Program fees are not eligible for tax receipts; however, a tax receipt will be issued for donations over and above the program fee amount. Full Cost of Room, Meals, Program Activities: 5 Days for Child/Young Adult participant I am bringing family members/ care givers/ friends (with me at a cost of $ per person) (The program fee of $ covers the full cost of meals, accommodations and MODC administrative costs) $650/per child/teen Participant (Early Bird rate $600) = $ x $402.50/per parent/caregiver (Early Bird Rate $352.50) I am making a tax-deductible donation to Conductive Education over and above the fee in the amount of: (Please provide a separate cheque for the donation. A tax receipt will be issued) Total Enclosed: =$ $ $ Method Of Payment Visa MasterCard American Express Cheque enclosed - Cheque# Authorized Signature of Cardholder: Print Name Exactly as Shown on Credit Card: Card No.: Expiry Date on Card: CE 07/12 Page 10 of 10 CE 2015 Brigadoon MODC March Break Camp

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