Louisiana School for the Visually Impaired Orientation and Mobility Summer Camp Programs May 31 June 4 and June 7 11, 2015
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1 Louisiana School for the Visually Impaired Orientation and Mobility Summer Camp Programs May 31 June 4 and June 7 11, 2015 To: Interested Parents and Students Re: Camp Registration Forms Thank you for your interest in LSVI s summer camp programs. Enclosed is a copy of the registration forms needed for participation. Please fill out all forms and mail or fax back to us as soon as possible. **LSVI camps are open to Louisiana residents only.** It is important that the following information be included on the registration forms as indicated: 1. Health insurance numbers 2. Medical information (including medications, if any) 3. Social security number 4. Date of birth 5. Physician signatures ********************************************************* Please fax or mail the registration forms to: Fax#: Address: Louisiana School for the Visually Impaired Attn: O&M Department/Summer Camps P.O. Box 4328 Baton Rouge, Louisiana For more information please call LSVI at Registration Deadline: May 1, 2015 Registration is limited Camper slots awarded on a first come/first served basis
2 Camp Dates/Please Check One: Louisiana School for the Visually Impaired Orientation and Mobility Summer Camp Programs **Registration Deadline: May 1, 2015** May 31 st to June 4 th for Grades 2 nd to 6 th June 7 th to 11 th for Grades 7 th to 12 th (Please use the grade your child will be entering next school year.) Student Name: Parish: Date of Birth: Age: Social Security Number: Current School Grade Level: Sex: Male Female Race (food services) T-Shirt Size/Please Circle One: Youth Size: S M L XL Adult Size: S M L XL Camps are open to Louisiana residents only. Parent's Name: Full Address: Home Number: Work Number: Cell Number: Additional Emergency Numbers: Will your child be staying in the dorm? Yes No What is your child s diagnosed visual impairment? Please list below any food allergies (required for food services): The Orientation and Mobility Summer Camp program is an intense program designed to enhance independent cane, travel, and orientation skills as well as living skills such as shopping, cooking, use of public transportation, and leisure/physical recreation. Due to high level physical requirements and program intensity, campers must be capable of independent self-help skills such as dressing, toileting, eating, and bathing. My child is capable of all self-help skills. Yes No LSVI offers academic enhancement programs in the areas of Braille, orientation and mobility, Nemeth code, math, etc. during the non-camp weeks of summer school: June 1-4, June 8-11, June Is your child interested in attending the academic enhancement programs? Yes No Page 1
3 PARENT COMPLETES THIS PAGE Louisiana Schools for the Deaf and Visually Impaired Health Information School Year: Name: Date of Birth: SSN: Sex: Race: Medicaid/LaChip: (attach copy of card) #: Medical Insurance: (attach copy of card) Company Name: Policy #: Group #: Private Pay: (Out of pocket) Yes List all medications taken by student at home: Medication Allergies and type of reaction: None FOOD Allergies and type of reaction: None Does your child require an EPI-PEN? Yes No Any other types of allergies? (ex-bee stings, latex, etc): Has your child ever had any of the following? Enter C Tracheostomy Heart Condition for current conditions and P for past conditions. Feeding Tube Pacemaker Measles Tuberculosis (TB) ADD / ADHD VP Shunt Chicken Pox Asthma Mood Disorder Dialysis Shunt CMV Seizures / Epilepsy Usher Syndrome Braces/Dental Appliance Meningitis (spinal) Diabetes Tubes in Ears(PE Tubes) Cerebral Palsy Artificial Limb Hearing Problems Vision Problems Other (please list): If yes to any of the above, please list necessary accommodations and/or PE, activities and competitive sports that are NOT allowed: Has your child ever had any surgeries or been hospitalized for medical reasons? Yes No If yes please list: (include hospital, date, reason hospitalized) Has your child ever had treatment or been hospitalized in a psychiatric or behavioral health facility? Yes No Does your child have a special diet? If yes please list: Yes No Visual Impairment Complete below Hearing Impairment Complete Below Wear glasses (circle) Sometimes/Always/Lost/Broken Cause of hearing impairment: Cause of visual impairment: Age of onset: Diagnosed by age: Diagnosed by age: Age of onset: Aided by age: Prosthetic Eye Right Left Wear hearing aid (please circle) 1 aid 2 aids Have a private eye doctor: YES NO Have a cochlear implant (circle) Left Right If yes, name and location of eye doctor: Cochlear Implant Date: Last mapped:!!please attach an updated copy of all immunizations. I declare the information provided on this form is correct and true to the best of my knowledge and belief. Parent/Guardian Signature PRINT Parent name Today s Date Best phone # to contact parent: Page 2 School use only: JPAMS entered on / / by
4 Medication Order Form Louisiana Schools for the Deaf and Visually Impaired Student Health Center Phone (225) (Voice/VP/TTY) Fax (225) This form must be completed by a licensed physician, dentist or nurse practitioner Orders sent by fax are acceptable Any medication changes/additions/discontinuations require new medication orders Additional copies of this sheet may be used if more space is needed Student: DOB: Date: ALLERGIES: Relevant Diagnosis(es): Medication: Strength of Medication: Dosage (amount to be given): Route: Frequency: Duration of Medication Order: Until end of school term Other Desired Effect: Possible side-effects of medication: Any contraindications for administering medication: Notify Me If: Licensed Prescriber Signature and Credential (i.e., MD, NP, DDS) Date Prescriber Name PLEASE PRINT: Address: Phone Fax * Additional copies of this sheet may be used if more space is needed Page 3
5 School Year: LOUISIANA SCHOOLS FOR THE DEAF and VISUALLY IMPAIRED (LDSVI) PLEASE REVIEW THIS PAGE CAREFULLY and ANSWER ALL QUESTIONS BEFORE SIGNING. MEDICAL PERMISSIONS Yes No Permission is given for my child to be examined by the school pediatrician and nursing staff for care and treatment of minor injuries and illnesses that arise while my child is at school. This may include giving over-the-counter and/or prescription medication. The school pediatrician does not prescribe medication for behavioral issues (ex. ADHD). Additionally, permission is given to administer medication to my child as ordered by other professionals/physicians licensed to prescribe these medications. Yes No Permission is given for trained dorm staff and/or trained teachers/para-professionals to administer medication when on field trips, sports activities, weekend stays, etc. NOTE: In EMERGENCIES, LSDVI will seek appropriate emergency care. AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION PERMISSION Yes No In an emergency medical situation, I give permission to LSD/LSVI to release my child's health information to the emergency contact for the purposes of emergency treatment. Health Insurance/Medicaid Please ensure we have an up to date copy of your child s current health insurance and/or Medicaid card information at registration. This may be needed if your child becomes ill or injured while at school. Parents/Guardians are financially responsible for health services provided by agencies other than the school. This may include, but not be limited to: ambulance services, physician s billing, prescription medication or co-payments and laboratory/x-ray services My signature below indicates I have read and understand the medication policies and health procedures of LSDVI. I have provided accurate information and I have given or denied permission according to my responses above. I am responsible for giving LSDVI any changes to this information IMMEDIATELY IN WRITING including changes in any permission decisions. Parent/Guardian Signature Date Student Name (printed) Page 4
6 LOUISIANA SCHOOL FOR THE VISUALLY IMPAIRED MINOR RELEASE Student's Name Please check one of the following boxes stating your agreement or refusal, then sign and date the form. [ ] I hereby agree to allow my child to participate in any media involvement for educational purposes. I agree that I am to receive no compensation, financial or otherwise. I further agree that my child's participation confers upon me no rights of use, ownership, or copyright whatsoever. I release the Louisiana School for the Visually Impaired, its employees, agents, and assigns from all liability for any claims by me or any third party in connection with his/her participation. I also agree to the use of my child's likeness, portrait, pictures, voice, and/or biographical material about him/her for program publicity and educational promotional purposes. [ ] I do not agree to allow my child to participate in any media events; nor do I allow my child's name, likeness, portrait, pictures, voice and/or biographical information to be used for program publicity or educational promotional purposes. Parent/Guardian s Signature Date **Registration Deadline: May 1, 2015** Page 5
7 BOBBY J INDAL GOVENOR State of Louisiana Office of Risk Management PAUL W. RAINWATER COMMISSIONER OF ADMINISTRATION HOLD HARMLESS AGREEMENT STUDENT S NAME: LSD LSVI By signing this document, I agree to the following: In consideration of the benefit received from my driving, or being transported in, a state-owned vehicle or vehicle rented to the State of Louisiana, State Department, Agency, Board or Commission, or authorized driver thereof, I voluntarily and knowingly assume any risk associated therewith and waive my right to assert any claim against the State of Louisiana, or any of its Departments, Agencies, Boards and Commissions, as well as its officers, agents, servants, employees and volunteers for injury or damage to my person or property resulting from my presence in said vehicle. I further release and hold harmless the State of Louisiana, all State Departments, Agencies, Boards and Commissions, as well as its officers, agents, servants, employees and volunteers, from any and all claims, demands, causes of action, expense and liability arising out of injury or death to my person as a result of my driving or being transported in, a state-owned vehicle or vehicle rented to the State of Louisiana, State Department, Agency, Board or Commission, or authorized driver thereof. Print Name Signature Date Post Office Box Baton Rouge, Louisiana (225) Fax (225) An Equal Opportunity Employer Page 6
8 LOUISIANA SCHOOL FOR THE VISUALLY IMPAIRED PERMISSION TO TRANSPORT I,, the parent and/or legal guardian of, a student attending School in Parish, hereby give permission to the Louisiana School for the Deaf and Visually Impaired to provide all necessary transportation for my child between our home parish and LSVI located in Baton Rouge, Louisiana. Furthermore, I give permission for my child to be transported to and from any LSVI function or camp field trip while participating in LSVI Programs, Camps, and/or Activities. Parent/Guardian Signature Date Witness Date **Registration Deadline: May 1, 2015** Page 7
9 CAMP ACTIVITIES CHECKLIST PERMISSION FORM Parents/Guardians: The following list of activities may be scheduled to take place during one of the Camp Programs that your son or daughter is attending. Please review the list of possible activities and indicate your willingness to allow your son or daughter to participate in these activities. NOTE: Field trips are planned for the purpose of providing educational enrichment and enjoyment. These trips are carefully planned and are usually culminating activities to units of study. All scheduled activities will abide by the following guidelines: 1. Adherence to safety regulations and recommendations will be strictly enforced. 2. Only certified personnel will monitor specific activities such as lifeguards for all water based activities and certified SCUBA Divers for Introduction to SCUBA Diving. 3. Use of required/recommended safety equipment such as helmets and life vests. 4. Each activity will be provided at no charge to the students. 5. Extended activities will generally take place within a 2 to 3 hour drive of Baton Rouge. Indicate your approval by marking YES next to each activity; mark NO next to the activity for which you do not approve: YES NO LSVI Swimming Pool YES NO Liberty Lagoon Waterpark YES NO Introduction to SCUBA Diving YES NO Zip lining YES NO Day Trips to New Orleans YES NO Geocaching YES NO Local Movie Theater YES NO Canoeing YES NO Tandem Bicycling YES NO AMTRAK Passenger Train Trips YES NO Rock Climbing Walls YES NO Roller Skating YES NO Bowling YES NO Celebration Station (Baton Rouge) YES NO Other School Sponsored Activities within a 2 to 3 hour drive of LSVI Student Name: Parent/Guardian Signature: Date: Page 8
10 Additional Information Registration Deadline: May 1, 2015 Registration is limited Camper slots are awarded on a first come/first served basis What is your child s reading medium: Reg. Print Lrg. Print Braille Does your child need transportation to camp? [ ] Yes [ ] No Does your child need transportation from camp? [ ] Yes [ ] No **If available in your area, details regarding camp transportation will be sent at a later date. * * Do you plan to attend the Thursday* family cookout scheduled for 11:00 A.M. to 2:00 P.M.? [ ] Yes [ ] No *Thursday, June 4 for grades 2 6 *Thursday, June 11 for grades 7 12 If yes, please indicate the number of family members who will be attending the Thursday luncheon: **DID YOU INCLUDE THE SOCIAL SECURITY NUMBER ON PAGE 1 & 2? **DID YOU COMPLETE INSURANCE INFORMATION ON PAGE 2? **DID YOU COMPLETE ALL MEDICAL INFORMATION IF YOUR CHILD TAKES MEDICATION INCLUDING A DR. s SIGNATURE ON PAGE 3? Please be sure that Pages 1-10 are completed before sending! Incomplete applications will be returned. Page 9
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