Family Support Network

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1 Special Services for Special Families Web: February 2016 Over the weekend of May 13, 14 and 15th Family Support Network and the Orange County community will be hosting its 23rd Annual Camp TLC event! TLC stands for Teaching, Loving, Care. Camp TLC is a wonderful family experience accomplished through the blending of inspirational speakers and educational workshops led by parents, nationally renowned speakers, and experienced local professionals. The camp is held in a beautiful country setting at the Irvine Ranch Outdoor Education Center in the foothills of Orange County. This setting creates a feeling of camaraderie among the participating families. Provided on site will be a complete camp staff of doctors, nurses and childcare providers. This is an opportunity your entire family will not want to miss! To be eligible for camp your child with special needs must be: Six months of age by May 31st, 2016 Under the age of five, except for those children whose fifth birthday falls in the month of May. Experiencing a significant long-term medical condition, or is receiving special education services from a school district program OR Regional Center Enclosed you will find a camp application, brochure and a medical release form (to be completed for any children who have medical concerns, such as currently taking medications, requiring supportive equipment, has a tracheotomy, etc). These forms should be completed as soon as possible, prior to the April 1 deadline, and returned to Family Support Network. Due to the availability of accommodations, we can only sponsor 40 families. Therefore, applications will be considered on a first-come-first-serve basis. The enclosed brochure describes this unique weekend experience. To ensure that your family receives the earliest consideration possible, please return this application immediately, along with the $40.00 application fee. You may request a waiver of the fee if your family is experiencing extreme financial hardship. The Medical Release Form must be returned by April 1. All forms can be sent to Family Support Network, ATTN: Camp TLC, at the above address. Remember, only 40 families can attend. Applications should be forwarded as soon as possible and must be received no later than April 1, Families who have participated in a previous camp are not eligible to participate in this year s camp. We look forward to a very positive and rewarding Camp TLC event this year. If you have any questions, please contact Family Support Network at (714) Sincerely, THE CAMP TLC COMMITTEE

2 CAMP TLC APPLICATION May 13, 14 and 15, 2016 For Office Use Only # Received Nursing Room # # in *Camp is on a first-come-first-serve basis. Return this application form as soon as possible. Name: Last First Spouse Address: Street Apt # City State Zip Code Phone Numbers: Day Night # of children attending Will your child(ren) require nursing care? Yes No Do YOU have any medical concerns we need to be aware of? If yes, please explain: Name of agency that referred you to Camp TLC: MEDICAL INFORMATION FOR CHILD WITH SPECIAL NEEDS (CHILD #1) Child s Name: Date of Birth: Emergency Contact (Name/Number): Child s Doctor (Name/Number): Disability: Medications: Special medical conditions: Special medical equipment you will bring: Regional Center client? Yes No MEDICAL INFORMATION FOR CHILD WITH SPECIAL NEEDS (CHILD #2) Child s Name: Date of Birth: Emergency Contact (Name/Number): Child s Doctor (Name/Number): Disability: Medications: Special medical conditions: Special medical equipment you will bring: Regional Center client? Yes No Please continue application on back

3 Camp TLC Application Continued Address Join our list? Yes No Others Attending (Siblings): Are any of these children receiving services? To be eligible for camp, your child with special needs must be at least 6 months by May 31st and under the age of 5, except for those whose 5th birthday falls in the month of May. PLEASE NOTE THE FOLLOWING: Camp IS NOT a resort hotel with all the amenities. It is an outdoor camp in a wilderness area. You may be required to use communal showers and restroom facilities, somewhat like a college dorm. Keep in mind that the area is dusty and hilly in the foothills of Orange County. Please keep the medical needs of your children in mind when you decide to attend this seminar. Child care will be provided in a group setting. Formulas and medications will not be provided at camp, but secure refrigerated storage facilities are available for your child s formula and medications. The camp will not provide any special equipment. All equipment you bring with you must be marked with your name, and you must assume all responsibility for the safety and condition of your equipment. Physician Release is required for your child with special needs to attend camp if your child will be receiving nursing care/supervision, prescribed medication or special equipment. Family Support Network cannot provide transportation. Before submitting this application, please make sure your family has a ride to and from camp. There is no alcohol allowed on the conference grounds. This camp is limited to immediate family members only. Please include with your application a $40.00 non-refundable check (reservation fee) payable to Family Support Network. (If requested, this fee may be waived in case of extreme financial hardship) Mail or Fax Completed Application Packet to: Family Support Network ATTN: Camp TLC *Applications must be received before: April 1, 2016 *As a participant in this seminar, you are responsible for the health, welfare and safety of yourself and your family. I hereby release Family Support Network and volunteers from all liability connected with the seminar, and agree to hold them harmless from any damage or injury that may occur as a result of participating in this activity. Signature Date

4 Camp TLC Application Continued Please check all the topics you would be interested in getting more information about: IHSS (In-Home Support Services) SSI (Supplemental Security Income) Medi-Cal Waiver Therapy Coverage Inclusion/Mainstreaming IEP (Individualized Education Plan) Medical Issues Regional Center of Orange County Medical Issues Support Groups All of the above Other:

5 For Office Use Only Child s age Special equipment Notes CAMP TLC MEDICAL RELEASE/DESCARGO MÉDICO (For child with medical concerns only/para el niño con necesidades especiales solamente) Medical Information (Información médica) Name (Last, First)/Nombre (Apellido, Primer) Parent/Guardian Name (Nombre Padre) Address (Dirección) City (Ciudad) Zip Code (Codigo Postal) Phone, including area code Child s DOB/Age Male/Female (Teléfono y edad) (Fecha de nacimiento) (Hombre/Mujer) ALLERGIES (Please list)/alergias (Favor de listar): FOLLOWING PORTION TO BE COMPLETED BY CHILD S PHYSICIAN This person is in satisfactory condition to attend Camp TLC and may engage in all usual activities except as noted: Licensed Physician s Name: Licensed Physician s Signature: Date: Physician s Address: Phone: Signature of Parent/Guardian: Date: Please return signed Medical Release Form by April 1st, 2016 Favor de devolver esta Forma de Descarga Médica firmada por usted y el médico de su niño antes del 1 de Abril Mail or Fax to: Family Support Network ATTN: Camp TLC