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Dream Street @ Canyon Ranch Founded and facilitated by the
Dream Street @ Canyon Ranch Founded and facilitated by the Dream Street Foundation, The Dream Street program at Canyon Ranch acts as a more intimate, mature and developmental experience. For our young adults aged 18-24 dealing with life threatening illnesses, Dream Street creates an honest atmosphere and a week of healing through our programs. Each year our young adult program is held at the beautiful Canyon Ranch Spa & Resort in Tuscon, Arizona. During the week you are able to participate in various activities such as swimming, tennis, golf, weight training and exercise classes. All classes are geared specifically for our group needs. Lectures are held on healthy life styles, food choices, coping when faced with job discrimination and many more topics. We provide these lectures and leisure activities to allow you a balanced, active and intellectual experience. At our core at Canyon Ranch, we hold daily focus groups that allow you as an individual to share and discuss your personal challenges in a safe and caring space. With experienced staff amongst you and surrounded by a group of peers faced with similar obstacles, contribution is important to gain maximum benefit from our program. To be considered for participation in this program please fill out the attached application. Is it important that you answer all questions completely so we can make your week at Canyon Ranch an unforgettable experience. A Dream Street counselor will be contacting you to answer any questions and provide you with additional information. Thank you. RETURN YOUR APPLICATION TO: Dream Street Foundation 324 South beverly Drive, Suite 500 Beverly Hills, CA 90212 DREAM STREET 324 SOUTH BEVERLY DRIVE, SUITE 500 • BEVERLY HILLS, CALIFORNIA 90212 • [email protected] Arizona • Arkansas • California • Mississippi • New Jersey * Please attach a current photo Session: July 28 2013 June 21 -- August June 28,4,2015 August 2 - August 9, 2015 TO be BE filled FILLED APPLICANT To outOUT by BY applicant only ONLY Date____________,201_____ Age_____________ PLEASEPRINT Sex: M F General Information Name:_______________________________________________________________________Dateofbirth:___________________ Last First Address:____________________________________________________________________________________________________ Street City State Phone:___________________________________________________ Home ZipCode ___________________________________________________________ Cell E-mailAddress:______________________________________________________________________________________________ SocialSecurityNumber:_______________________________________________________________________________________ Parent/Guardian/Spouse:_____________________________________________________________________________________ Phone:______________________________________________________________________________________________________ Home Cell Work Address:_____________________________________________________________________________________________________ Street City State ZipCode Physician Information (Required) PrimaryPhysician:____________________________________________________________________________________________ ()______________________________________()_________________________________________ Phone Fax Hematologist/Oncologist:________________________________________________________________________________________ ()______________________________________()_________________________________________ Phone Fax 1 Insurance Information Doyoucarrymedical/hospitalinsurance? Yes No Carrier:_____________________________________________________________________________________________________ PolicyorGroupNumber **Pleasebringyourinsurancecardwithyoutocamp Contact Information Contactincaseofemergency:___________________________________________________________________________________ Name:______________________________________________________________________________________________________ Last First Relationship Address:_____________________________________________________________________________________________________ Street City State ZipCode Phone:______________________________________________________________________________________________________ Home Cell Work E-Mail:_____________________________________________________________________________________________________ Dream Street Information HaveyoueverattendedaDreamStreetcamp? Yes No What State? HowdidyouhearaboutDreamStreet?____________________________________________________________________________ ___________________________________________________________________________________________________________ Whoreferredyou?_____________________________________________________________________________________________ Whathospitalareyoutreatedat?_________________________________________________________________________________ City State Whatisthenameofthemajorairportinyourarea?___________________________________________________________________ DreamStreetsuppliesT-shirtsforeachday.Pleaseindicateyoursize. s m l xl xxl xxxl xxxxl 2 Medical Profile (AllinformationisprivateandconfidentialforusebyDreamStreetonly) Diagnosis:___________________________________________________________________________________________________ _____________________________________________________________________________________________________________ DateDiagnosed____________________CurrentHeight_____________________Current Weight in Lbs____________________ Treatments:__________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Otherrelateddiagnosis(e.g.Diabetes,heartdisease,Asthma)_________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Pasttreatment: Date: Chemo XRT Transplant Surgery ____________ ____________ ____________ ____________ Currenttreatment: Chemo XRT Surgery Other Date: ____________ ____________ ____________ ____________ Ifyouhavehadbloodcountsdrawninthelastmonth,pleaseincludethosecountsforus,especiallyifyourdiagnosisortreatment mayalteryourcounts. IfyouhavesicklecellpleaselistyourHGb/HCT&RETIC __________ __________ Ifyouhaveanyformofcancer,pleaselistyourANC,HGb/HCT.PLTCount,etc. __________ __________ Date Date Counts Counts Haveyouhadanytherapyinthelast30days? Yes NoDateoftherapy____________________ (bloodtransfusions,chemotherapy,hospitalization)Pleasedescribe:_____________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Dateoflasthospitalization_______________________________ Dateoflasttransfusion___________________________________ Willyouneedlabsdrawnduringcamp? Yes No Whoshouldtheresultsbefaxedto?____________________________ FaxNumber_______________________________________ Haveyouhadanychangeinyourhealthstatusrecently? (Weightlossorgain,flu,unexpectedhospitalization,operation,etc.) Yes No Ifyes,pleasedescribe:_________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ 3 Medications PleaselistALLmedicationsyouarecurrentlytaking(scheduledmeds&prnmeds) **Pleasebringallofthesemedswithyoutocamp.Makesureyoubringenoughfortheweek. Name of Medication Exact Dosage/Frequency Prescribing Doctor _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ _____________________________________ ____________________________ ______________________________ Additional Medical Information Doyouhaveanyspecialneedsmedicallyorphysicallimitations? (Wheelchairdependent,walker,crutches,prostheses,oxygen,etc.) Yes No Ifyes,pleaseexplain:__________________________________________________________________________________________ ___________________________________________________________________________________________________________ Willyouneedassistancewithanyofyourmedicalcare? Yes No Ifso,pleasedescribe__________________________________________________________________________________________ ___________________________________________________________________________________________________________ Doyouhaveanytypeoftubeorcatheter? (broviac,Portacath,Groschong,GTube,Dialysisorother) Yes No Please bring supplies for dressing changes and/or flushes or catheters. ** Please bring all supplies and equipment necessary for the week. AllergiestoFood? Yes No Whichfood(s)?____________________________________________________ Doyourequireaspecialdiet? Yes No Describe__________________________________________________________ Environmentalallergies Yes No Nameallergies_____________________________________________________ AllergiestoMedicines Yes No Whichmedicines?__________________________________________________ HaveyouhadChickenPox Yes No HaveyouhadMeasles Yes No HasyourdoctorplacedanylimitationsonyouractivitieswhileatCanyonRanch? Yes No Ifyes,pleaseexplain__________________________________________________________________________________________ Signature X Important: PleasenotifytheDreamStreetofficeif youhavebeenexposedtoanycommunicabledisease duringthethreeweekspriortocamp. PrintName 4 In order to make your stay at Canyon Ranch meaningful for you, complete the following questionnaire. All information is strictly confidential. Please answer all questions Haveyoueverbeenawayfromhome? Yes No Forhowlong?_____________ WouldyouconsideryourselfShy? Yes No Areyoucomfortablespeakinginagroup? Yes No Haveyoueverbeenintherapy? Yes No Ifyes,whichtype?Grouptherapy Yes No Family Yes No Yes No Other Yes No Yes No Currently? Yes No Individual Haveyoueverbeendiagnoseddepressed? Describeyourdepression:______________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Haveyoueverattemptedsuicide? Yes NoHowlongago?__________ Isanyoneinyourfamilychemicallydependent? Yes No Doyoueverfeelanxious? Yes No Doyouconsideryourselfdepressed? Yes No When?____________________________________________ Whatisyourpresentstateofmind?______________________________________________________________________________ Areyourparentslivingtogether? Howmanyareinyourfamily? Yes No _______brother(s)_______Sister(s)_______Father_______Mother _______Stepfather_______Stepmother Whodoyoulivewith? Mother Stepfather Stepmother Roommate Aunt Who do you live with? brother(s) Brother(s) Sister(s) Sister(s) Father Father Mother Stepfather Stepmother Roommate Uncle Spouse Aunt Cousin(s) Cousin(s) boyfriend Boyfriend Girlfriend Girlfriend Spouse Other _________________ Whatgradeinschoolhaveyoucompleted?10th11th12th1styearcollege 2ndyearcollege Other_____ Ifyoucouldchangeonethingaboutyourfamily,whatwoulditbe?______________________________________________________ Ifyoucouldchangeonethingaboutyourself,whatwoulditbe?________________________________________________________ Whatisyourstrongestcharacteristic?_____________________________________________________________________________ Whatareyoureducationalgoals?_________________________________________________________________________________ Whatareyourcareergoals?_____________________________________________________________________________________ Whatisanexampleofsomethingthatyouareproudof?______________________________________________________________ ___________________________________________________________________________________________________________ 5 Wheredoyouseeyourselfinoneyear?____________________________________________________________________________ Wheredoyouseeyourselfinfiveyears?___________________________________________________________________________ Whichlivingpersondoyoumostadmire?__________________________________________________________________________ Whoisthemostinfluentialpersoninyourlife?_____________________________________________________________________ Why:___________________________________________________________________________________________________ Whohasbeenthemostsupportiveofyou?_________________________________________________________________________ Whoisthemostimportantpersoninyourlife?Whatcouldyoudotoimprovetherelationship?Willyoueverdoit?_______________ ______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Whoisyourfavoriteheroinreallife?_____________________________________________________________________________ Whatdoyoudislikemostaboutyourappearance?___________________________________________________________________ Relativetothepopulationatlarge,howdoyourateyourphysicalattractiveness?___________________________________________ Yourintelligence?AbCDF Yourpersonality?AbCDF Whatdoyoudoonyourfreetime?________________________________________________________________________________ Doyouhaveanopenrelationshipwithyourdoctor?__________________________________________________________________ Doyoufeelhe/sherespectsyouasanadult?________________________________________________________________________ Whatgradewouldyougiveyourdoctorfortheoveralljobhe/shedoes?AbCDF Forhis/herpatience?AbCDF Forhis/herfriendliness?AbCDF Doyoufeelyourdoctorisaccessibleandmeetsyourneeds?___________________________________________________________ Doyouusuallysaywhatyoureallythinkorwhatyouthinkotherpeoplewanttohear?______________________________________ Whichlivingpersondoyoumostdespise?__________________________________________________________________________ Describeyourgreatestfear:_____________________________________________________________________________________ Whatisyourideaofhappiness?__________________________________________________________________________________ Whatisyourgreatestregret?____________________________________________________________________________________ Whatisyourbiggestflaw?______________________________________________________________________________________ Whatchallengesyou?______________________________________________________________________________________ 6 Whatareyourmostcompulsivehabits?Doyoustruggletobreakthesehabits?_____________________________________________ Whatareyourmostcompulsivehabits?Doyoustruggletobreakthesehabits?_____________________________________________ Whatareyourmostcompulsivehabits?Doyoustruggletobreakthesehabits?_____________________________________________ ___________________________________________________________________________________________________________ Whatareyourmostcompulsivehabits?Doyoustruggletobreakthesehabits?_____________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Whendidyoulastcryinfrontofanotherperson?byyourself?_________________________________________________________ ___________________________________________________________________________________________________________ Whendidyoulastcryinfrontofanotherperson?byyourself?_________________________________________________________ Whendidyoulastcryinfrontofanotherperson?byyourself?_________________________________________________________ Whatthingsaretoopersonaltodiscusswithothers?__________________________________________________________________ Whendidyoulastcryinfrontofanotherperson?byyourself?_________________________________________________________ Whatthingsaretoopersonaltodiscusswithothers?__________________________________________________________________ Whatthingsaretoopersonaltodiscusswithothers?__________________________________________________________________ Inconversationsdoyouintendtolistenortalkmore?_________________________________________________________________ Whatthingsaretoopersonaltodiscusswithothers?__________________________________________________________________ Whatareyourmostcompulsivehabits?Doyoustruggletobreakthesehabits?_____________________________________________ Inconversationsdoyouintendtolistenortalkmore?_________________________________________________________________ Inconversationsdoyouintendtolistenortalkmore?_________________________________________________________________ Howoldwouldyoubeifyoudidn’tknowhowoldyouare?____________________________________________________________ Inconversationsdoyouintendtolistenortalkmore?_________________________________________________________________ ___________________________________________________________________________________________________________ Whatareyourmostcompulsivehabits?Doyoustruggletobreakthesehabits?_____________________________________________ Howoldwouldyoubeifyoudidn’tknowhowoldyouare?____________________________________________________________ Howoldwouldyoubeifyoudidn’tknowhowoldyouare?____________________________________________________________ Woulditembarrassyoutocryinfrontofyourfriends?________________________________________________________________ Howoldwouldyoubeifyoudidn’tknowhowoldyouare?____________________________________________________________ Whendidyoulastcryinfrontofanotherperson?byyourself?_________________________________________________________ Whatareyourmostcompulsivehabits?Doyoustruggletobreakthesehabits?_____________________________________________ ___________________________________________________________________________________________________________ Woulditembarrassyoutocryinfrontofyourfriends?________________________________________________________________ Woulditembarrassyoutocryinfrontofyourfriends?________________________________________________________________ Whatthoughtorsentimentwouldyouliketohavecopiedandputintoonemillionfortunecookies?____________________________ Woulditembarrassyoutocryinfrontofyourfriends?________________________________________________________________ Whatthingsaretoopersonaltodiscusswithothers?__________________________________________________________________ ___________________________________________________________________________________________________________ Whendidyoulastcryinfrontofanotherperson?byyourself?_________________________________________________________ Whatthoughtorsentimentwouldyouliketohavecopiedandputintoonemillionfortunecookies?____________________________ Whatthoughtorsentimentwouldyouliketohavecopiedandputintoonemillionfortunecookies?____________________________ ___________________________________________________________________________________________________________ Whatthoughtorsentimentwouldyouliketohavecopiedandputintoonemillionfortunecookies?____________________________ List two talents, subjects or activities that come naturally to you:_________________________________________________________ Inconversationsdoyouintendtolistenortalkmore?_________________________________________________________________ Whendidyoulastcryinfrontofanotherperson?byyourself?_________________________________________________________ Whatthingsaretoopersonaltodiscusswithothers?__________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ *belowaresometopicsthatwillbediscussedinfocusgroups.Pleasecheckwhichonesyouhaveinterestin: ___________________________________________________________________________________________________________ List two things that you are struggling with in your life at this moment:___________________________________________________ Howoldwouldyoubeifyoudidn’tknowhowoldyouare?____________________________________________________________ Whatthingsaretoopersonaltodiscusswithothers?__________________________________________________________________ Inconversationsdoyouintendtolistenortalkmore?_________________________________________________________________ *belowaresometopicsthatwillbediscussedinfocusgroups.Pleasecheckwhichonesyouhaveinterestin: *belowaresometopicsthatwillbediscussedinfocusgroups.Pleasecheckwhichonesyouhaveinterestin: bodyImage Family WhyMe? Dying Sex Future Intimacy Death Fears Anger *belowaresometopicsthatwillbediscussedinfocusgroups.Pleasecheckwhichonesyouhaveinterestin: ___________________________________________________________________________________________________________________________ Woulditembarrassyoutocryinfrontofyourfriends?________________________________________________________________ Inconversationsdoyouintendtolistenortalkmore?_________________________________________________________________ Howoldwouldyoubeifyoudidn’tknowhowoldyouare?____________________________________________________________ bodyImage Family Dying Sex Intimacy Death bodyImage Family WhyMe? WhyMe? Dying SexRelationships Future Future Anxiety Intimacy Other____________________ Death Fears Fears Anger Anger FearofRelapse SubstanceAbuse SelfEsteem What are two thingsyou are grateful for in your life atDying this moment:______________________________________________________ bodyImage Family WhyMe? Sex Future Intimacy Death Fears Anger_ Whatthoughtorsentimentwouldyouliketohavecopiedandputintoonemillionfortunecookies?____________________________ Howoldwouldyoubeifyoudidn’tknowhowoldyouare?____________________________________________________________ Woulditembarrassyoutocryinfrontofyourfriends?________________________________________________________________ FearofRelapse SubstanceAbuse SubstanceAbuse SelfEsteem SelfEsteem Relationships Relationships Anxiety Anxiety Other____________________ Other______________________ FearofRelapse Doyouhaveanyothersuggestionsoftopicsthatyouwouldliketodiscuss?_______________________________________________ ___________________________________________________________________________________________________________________________ FearofRelapse SubstanceAbuse SelfEsteem Relationships Anxiety Other_____________________ ___________________________________________________________________________________________________________ Woulditembarrassyoutocryinfrontofyourfriends?________________________________________________________________ Whatthoughtorsentimentwouldyouliketohavecopiedandputintoonemillionfortunecookies?____________________________ Doyouhaveanyothersuggestionsoftopicsthatyouwouldliketodiscuss?_______________________________________________ Doyouhaveanyothersuggestionsoftopicsthatyouwouldliketodiscuss?_______________________________________________ Doyouhaveanyothersuggestionsoftopicsthatyouwouldliketodiscuss?_______________________________________________ *belowaresometopicsthatwillbediscussedinfocusgroups.Pleasecheckwhichonesyouhaveinterestin: ___________________________________________________________________________________________________________ Whatthoughtorsentimentwouldyouliketohavecopiedandputintoonemillionfortunecookies?____________________________ Doyouhaveanyissuesthatyouwouldliketotalkaboutwithacounselor1:1andnotshareingroup? Yes No bodyImage Family WhyMe? Dying Sex Future Intimacy Death Fears Anger ___________________________________________________________________________________________________________ *belowaresometopicsthatwillbediscussedinfocusgroups.Pleasecheckwhichonesyouhaveinterestin: Doyouhaveanyissuesthatyouwouldliketotalkaboutwithacounselor1:1andnotshareingroup? Yes Yes No No Doyouhaveanyissuesthatyouwouldliketotalkaboutwithacounselor1:1andnotshareingroup? Doyouhaveanyissuesthatyouwouldliketotalkaboutwithacounselor1:1andnotshareingroup? Yes No *belowaresometopicsthatwillbediscussedinfocusgroups.Pleasecheckwhichonesyouhaveinterestin: FearofRelapse SubstanceAbuse SelfEsteem Other____________________ bodyImage Family WhyMe? Dying SexRelationships Future Anxiety Intimacy Death Fears Anger_ Doyouhaveanyquestionsabouttheprogram? Doyouhaveanyothersuggestionsoftopicsthatyouwouldliketodiscuss?_______________________________________________ bodyImage Family WhyMe? Dying SexRelationships Future Anxiety Intimacy Death Fears Anger_ FearofRelapse SubstanceAbuse SelfEsteem Other____________________ Doyouhaveanyquestionsabouttheprogram? Doyouhaveanyquestionsabouttheprogram? ___________________________________________________________________________________________________________ Doyouhaveanyquestionsabouttheprogram? Doyouhaveanyothersuggestionsoftopicsthatyouwouldliketodiscuss?_______________________________________________ FearofRelapse SubstanceAbuse SelfEsteem Relationships Anxiety Other_____________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Doyouhaveanyissuesthatyouwouldliketotalkaboutwithacounselor1:1andnotshareingroup? Yes No Doyouhaveanyothersuggestionsoftopicsthatyouwouldliketodiscuss?_______________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Doyouhaveanyissuesthatyouwouldliketotalkaboutwithacounselor1:1andnotshareingroup? Yes No ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Doyouhaveanyissuesthatyouwouldliketotalkaboutwithacounselor1:1andnotshareingroup? Yes No Doyouhaveanyquestionsabouttheprogram? ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Doyouhaveanyquestionsabouttheprogram? ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Doyouhaveanyquestionsabouttheprogram? ___________________________________________________________________________________________________________ Do you know what a focus group is? Yes No ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Do know focus Yes No a focus Do you youdescribe know what what focus group group is? is?of Yes No Please youraaa understanding group_______________________________________________________ Do you know what focus group is? Yes No ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Please describe your understanding of a focus group_______________________________________________________ Please describe your understanding of a focus group_______________________________________________________ _________________________________________________________________________________________________________ Please describe your understanding of a focus group_______________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Do you understand that a focus group is scheduled daily at the ranch? Yes No _________________________________________________________________________________________________________ Yes No Do you know what a focus group is? ___________________________________________________________________________________________________________ Do you understand understand that that aa focus focus group group is daily at at the Yes Yes No No Do you is scheduled scheduled daily the ranch? ranch? Do you understand that a focus group is scheduled daily at the ranch? Yes No Please youra understanding a focus group_______________________________________________________ Do youdescribe know what focus group is?of Yes No 7 _________________________________________________________________________________________________________ Do youdescribe know what focus group is?of Yes No Please youra understanding a focus group_______________________________________________________ 7 7 _________________________________________________________________________________________________________ 7 _________________________________________________________________________________________________________ Please describe your understanding of a focus group_______________________________________________________ RELEASE FOR EMERGENCY TREATMENT AND LIMITATION OF LIABILITY Frequently Asked Questions (Arizona) 9 I ________________________________________ am a camper or counselor (Camper/Counselor) over 18 years of age Please readtoeach item Camp belowDream and circle response best describes how you feel today using the who will travel and attend Street the during the year that of 201_____; or following scale: 9 What I am the parent, guardian or caregiver authorized to give consent for medical and dental care of ___________________________, is Dream Street? a camper or counselor (“Camper/Counselor”) who is under 18 years of age, who will travel to and attend Camp Dream Street 1- Not at all 2- Sometimes ening illnesses. We also provide programs for young adults, ages 18-24, at The Canyon Ranch 3-I hereby Lots ofauthorize the timethe Director, Doctor, or Nurse of Camp Dream Street to consent to any x-ray examination, anesthetic, Health Resort. Dream Street funds and operates programs in Arizona, Arkansas, California, Mismedical or surgical diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision 4- Almost all of the time sissippi and New Jersey. and upon the advice of a physician and surgeon licensed by the Arizona Medical Board, or to consent to an x-ray examination, Dream provides programs for to children with chronic and life threatduring the yearStreet of 201_____, (if a traditional caregiver, mycamping authorization is pursuant A.R.S. §4-15 14-5209). anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to the minor by a dentist licensed by the Arizona State Board of Dental Examiners. This authorization shall be effective whether such diagnosis, treatment or care is rendered at the office of or dentist, How supported dosaid youphysician feel in your life?at a hospital, at Camp Dream Street, or elsewhere, and shall remain effective wechild/ward lookingis for in to those that apply? whileWhat I am or are my said enroute or from or involved or participating in any program or activity of Camp Dream Street, unless earlier revoked by me in writing and delivered to the Director. We are looking for young people who are willing to participate in a group and share feelings with 1 2 3 4 others that are in similar Applicantsofmust willing to be open and honest with their feelI hereby acknowledge that forsituations. the proper functioning CampbeDream Street, a unique summer camp exclusively for individuals ings.with serious health issues, it is necessary that the doctor / nursing / therapist staff at the camp be able to discuss the Camper/Counselor’s health issues with the non-medical counseling and other staff so that the staff is able to assist with How much do you providing a campanxiety experience whichexperience? is sensitive to and consistent with the Camper/Counselor’s health issues, limitations, and requirements. While the camp staff does not provide health care, they need to understand the health conditions to assure that activities are will tailored to the needs, abilities and limitations of those attending the camp. How I know if I am accepted? 1 2 3 4 Once your application has been returned, a doctor Dreamand Street counselor will contact to filmed discuss your I further acknowledges that discussions between the nurses and the non-medical staff you may be for purposes application. in Dream each session limited, please your donors. application as soon as acknowledges possible. of promoting interestSpace in Camp Street byisthe generalso public andreturn by potential The undersigned that such discussions may include medical record information pertaining to the Camper/Counselor. I further understand that How often do you follow a healthy lifestyle? such film may be submitted to news organizations and other commercial broadcast facilities for human interest coverage of the Camp, its campers and staff or used at Camp Dream Street fundraising functions or to supplement a Camp Dream Street speech to hospitals, or organizations. accepted? What 1 happens 2 businesses, 3if I am 4groups If you are accepted to attend, one month prior to your departure, you will receive your airline In full consideration of the foregoing, the undersigned hereby authorizes the medical staff of Camp Dream Street, including ticket, as well as additional information. without limitation, its doctors, nurses and physical therapists, as applicable, to disclose the undersigned’s full medical record information to the non-medical staff of(circle Camp your Dreamresponse) Street for the purposes stated above and the undersigned further authoWhere are you in treatment? rizes that such medical information discussions between the medical staff and non-medical staff at Camp Dream Street may be filmed for the purposes stated above. Active Treatment Chronic What does it cost toRemission go to Dream Street atTreatment Canyon Ranch? On my own behalf and on behalf of my child/ward, I hereby expressly and hold harmless Camp Dream All Dream Street programs are free of charge. The Dreamrelease, Streetdischarge Foundation underwrites all proStreet, the Dream Street Foundation and Canyon Ranch and their respective agents, employees, officers, directors and gram and from travel to Canyon Ranch. representatives, anyexpenses liability or responsibility relating to or arising from any damage, loss, or injury sustained by Camper/ What Topic would you most like Dream to discuss week? Counselor while traveling to or from Camp Street,this while attending Camp Dream Street, while participating in any activities at Camp Dream Street or any trips or other activities sponsored by the Dream Street Foundation, or while staying in any accommodations provided or arranged by Camp Dream Street or by the Dream Street Foundation, other than any such liability Should Iwhich bring and if so, how much? or responsibility maymoney arise as awith result me of their gross negligence or willful misconduct. Without limiting the generality of are you most looking forward to this week? theWhat foregoing, this release includes within its scope any loss, damage or injury sustained a result of any ordinary negligence, You will need no money at Canyon Ranch. All food and services areascovered for you. However, whether active or passive on the part of Camp Dream Street, the Dream Street Foundation. or any of their officers, agents, there or is representatives. a gift shop which sells sundries, t-shirts and other items. employees The forgoing release is to be construed in accordance with the laws of the State of Arizona. It is intended to release claims which are known and which are as yet unknown. Accordingly. I hereby waive, on my own behalf and on behalf of my child/ ward, the provisions of any applicable statute which provides in substance: 1 of 2 8 This Page is Mandatory Pleasewriteastoryaboutyourselfandhowyourillnesshasaffectedyourlife. Pleaseuseanadditionalsheetofpaperifnecessary. 8 9 Frequently Asked Questions RELEASE FOR EMERGENCY TREATMENT AND LIMITATION OF LIABILITY (Arizona) 9 I ________________________________________ am a camper or counselor (Camper/Counselor) over 18 years of age who will travel to and attend Camp Dream Street during the year of 201_____; or is parent, Dream Street? 9 What I am the guardian or caregiver authorized to give consent for medical and dental care of ___________________________, a camper or counselor (“Camper/Counselor”) who is under 18 yearsfor of age, who will travel to and attendand Camp Street Dream Street provides traditional camping programs children 4-15 with chronic lifeDream threatduring the year of 201_____, (if a caregiver, my authorization is pursuant to A.R.S. § 14-5209). ening illnesses. We also provide programs for young adults, ages 18-24, at The Canyon Ranch Resort. the Dream Street funds and operates programs California,anesthetic, MisI Health hereby authorize Director, Doctor, or Nurse of Camp Dream Streetin to Arizona, consent toArkansas, any x-ray examination, medical or surgical or treatment, and hospital care to be rendered to the minor under the general or special supervision sissippi anddiagnosis New Jersey. and upon the advice of a physician and surgeon licensed by the Arizona Medical Board, or to consent to an x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to the minor by a dentist licensed by the Arizona State Board of Dental Examiners. This authorization shall be effective whether such diagnosis, treatment or care is rendered at the office said physician dentist, at athat hospital, at Camp Dream Street, or elsewhere, and shall remain effective What are weof looking fororin those apply? while I am or my said child/ward is enroute to or from or involved or participating in any program or activity of Camp Dream We are looking for young people are willing toDirector. participate in a group and share feelings with Street, unless earlier revoked by me in writingwho and delivered to the others that are in similar situations. Applicants must be willing to be open and honest with their feel- I hereby acknowledge that for the proper functioning of Camp Dream Street, a unique summer camp exclusively for inings. dividuals with serious health issues, it is necessary that the doctor / nursing / therapist staff at the camp be able to discuss the Camper/Counselor’s health issues with the non-medical counseling and other staff so that the staff is able to assist with providing a camp experience which is sensitive to and consistent with the Camper/Counselor’s health issues, limitations, and requirements. While the camp staff does not provide health care, they need to understand the health conditions to assure that How will I know if I am accepted? activities are tailored to the needs, abilities and limitations of those attending the camp. Once your application has been returned, a Dream Street counselor will contact you to discuss your Iapplication. further acknowledges discussions between the doctor and nurses and the non-medical staffas may be filmed for purposes Spacethat in each session is limited, so please return your application soon as possible. of promoting interest in Camp Dream Street by the general public and by potential donors. The undersigned acknowledges that such discussions may include medical record information pertaining to the Camper/Counselor. I further understand that such film may be submitted to news organizations and other commercial broadcast facilities for human interest coverage of the Camp, its campers and staff or used at Camp Dream Street fundraising functions or to supplement a Camp Dream Street What happens if I am accepted? speech to hospitals, businesses, groups or organizations. If you are accepted to attend, one month prior to your departure, you will receive your airline In full consideration the foregoing, the undersigned hereby authorizes the medical staff of Camp Dream Street, including ticket, as well asofadditional information. without limitation, its doctors, nurses and physical therapists, as applicable, to disclose the undersigned’s full medical record information to the non-medical staff of Camp Dream Street for the purposes stated above and the undersigned further authorizes that such medical information discussions between the medical staff and non-medical staff at Camp Dream Street may be filmed for the purposes stated above. What does it cost to go to Dream Street at Canyon Ranch? AllmyDream Street are of charge. The Dreamrelease, Streetdischarge Foundation underwrites all proOn own behalf andprograms on behalf of myfree child/ward, I hereby expressly and hold harmless Camp Dream Street, the Dream Streetexpenses Foundation Canyon Ranch and their respective agents, employees, officers, directors and gram and travel to and Canyon Ranch. representatives, from any liability or responsibility relating to or arising from any damage, loss, or injury sustained by Camper/ Counselor while traveling to or from Camp Dream Street, while attending Camp Dream Street, while participating in any activities at Camp Dream Street or any trips or other activities sponsored by the Dream Street Foundation, or while staying in any accommodations or arranged by Camp Street by the Dream Street Foundation, other than any such liability Should I provided bring money with me Dream and if so,orhow much? or responsibility which may arise as a result of their gross negligence or willful misconduct. Without limiting the generality of You willthis need no includes money within at Canyon Ranch. Alldamage food and services areascovered for you. However, the foregoing, release its scope any loss, or injury sustained a result of any ordinary negligence, there is aorgift shoponwhich sells sundries, t-shirts other items. whether active passive the part of Camp Dream Street, and the Dream Street Foundation. or any of their officers, agents, employees or representatives. The forgoing release is to be construed in accordance with the laws of the State of Arizona. It is intended to release claims which are known and which are as yet unknown. Accordingly. I hereby waive, on my own behalf and on behalf of my child/ ward, the provisions of any applicable statute which provides in substance: 1 10 of 2 Frequently Asked Questions “A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.” I have read and understood the medical history and information form, and the information I have given is true and correct. What is Dream Street? Dated: ______________, 201_____. Dream Street provides traditional camping programs for children 4-15 with chronic and life threatening illnesses. We also provide programs for X young adults, ages 18-24, at The Canyon Ranch X _____________________________________ _____________________________________ Signature Witness Health Resort. Dream Street funds and operates programs in Arizona, Arkansas, California, Mississippi and New Jersey. _____________________________________ _____________________________________ Print name Print Name What are we looking for in those that apply? PUBLICITY RELEASE We are looking for young people who are willing to participate in a group and share feelings with For goodthat andare valuable consideration from Dream Street must Foundation and Camp the adequacy and receipt others in similar situations. Applicants be willing to beDream openStreet, and honest with their feel- of which I hereby acknowledge, I hereby expressly grant to Dream Street Foundation and Camp Dream Street, or any third party eitherings. of them may authorize, and to their employees, agents and assigns, the right to photograph me (or my child/ward) and/ or make recordings of my/his/her voice, and the right to use pictures, recordings and other reproductions of my/his/her physical likeness or voice (as the same may appear in any still-camera photographs, videotape, and/or motion picture film) for any advertising, promotion and/or fundraising, without any further compensation. All such photographs, videotapes, motion picture will I know if I amoraccepted? films,How and recordings, and all negatives masters thereof, shall be the sole and exclusive property of Dream Street Foundation and Camp Street. OnceDream your application has been returned, a Dream Street counselor will contact you to discuss your application. Space in each session is limited, so please return your application as soon as possible. I hereby certify and represent that I have read the forgoing and fully understand the meaning and effect thereof and, intending to be legally bound. I have hereunto set my hand this ______________ day of ______________ 201______. What happens if I am accepted? X _____________________________________ Signature you are accepted X _____________________________________ Witness you will receive your airline If to attend, one month prior to your departure, ticket, as well as additional information. _____________________________________ _____________________________________ Print name Print Name What does it cost to go to Dream Street at Canyon Ranch? All Dream Street programs are free of charge. The Dream Street Foundation underwrites all program and travel expenses to Canyon Ranch. Should I bring money with me and if so, how much? You will need no money at Canyon Ranch. All food and services are covered for you. However, there is a gift shop which sells sundries, t-shirts and other items. 11 Frequently Asked Questions (Do not return with application) What is Dream Street? Dream Street provides traditional camping programs for children 4-15 with chronic and life threatening illnesses. We also provide programs for young adults, ages 18-24, at The Canyon Ranch Health Resort. Dream Street funds and operates programs in Arizona, Arkansas, California, Mississippi and New Jersey. What are we looking for in those that apply? We are looking for young people who are willing to participate in a group and share feelings with others that are in similar situations. Applicants must be willing to be open and honest with their feelings. How will I know if I am accepted? Once your application has been returned, a Dream Street counselor will contact you to discuss your application. Space in each session is limited, so please return your application as soon as possible. What happens if I am accepted? If you are accepted to attend, one month prior to your departure, you will receive your airline ticket, as well as additional information. What does it cost to go to Dream Street at Canyon Ranch? All Dream Street programs are free of charge. The Dream Street Foundation underwrites all program and travel expenses to Canyon Ranch. Should I bring money with me and if so, how much? You will need no money at Canyon Ranch. All food and services are covered for you. However, there is a gift shop which sells sundries, t-shirts and other items. How will I get to Canyon Ranch? You do not need to make any travel plans of your own. All travel plans will be made by Dream Street. A Dream Street counselor will meet you at the airport and take you directly to Canyon Ranch. Will anyone call me from Canyon Ranch? A Canyon Ranch program co-ordinator will call you to explain the services offered and book your appointments. If you do not book before you arrive you will be able to do it when you get there. Will I be able to contact people using my cell phone? There is a “No Cell Phone” policy at Canyon Ranch, however you will be able to use your cell phone at the main house. What will my accommodations be like? Although the program is co-ed, sleeping facilities are separate. In some cases, it might be dormitory style, however there are private bathrooms. Campers and staff are housed together. What do I wear at Canyon Ranch? Dream Street will provide you with daily t-shirts and a “what to bring” list will be sent with your airline information. We do not allow low-slung, baggy jeans. How do I contact Dream Street to check on my application process, or for any other questions I might have? You may e-mail us at: [email protected] Where to mail the completed form. Dream Street StreetFoundation Foundation Dream 324 South South Beverly BeverlyDrive, Drive,Suite Suite500 500 Beverly Hills, Hills,CA CA90212 90212 Beverly (424) 333-1371 These are some of the health services offered at Canyon Ranch you might enjoy? Rx for Exercise If you aren’t on a regular exercise program but would like to initiate one, an exercise physiologist can explain the health benefits of exercise, and custom design an exercise program in tune with your goals, interests and physical limitations. Learning proper and safe techniques for your personal physiology is emphasized. Exercise for Weight Loss Find out how much exercise is necessary for effective weight loss. An exercise physiologist will design a multi-dimensional exercise program, not only for permanent weight loss, but also for maintaining or increasing lean body mass. This will be tailored to your own unique physiology. Racquetball, Squash & Tennis Play any of these fast-paced sports to burn calories and get a good workout. There are indoor airconditioned courts for racquetball and squash, and outdoor-lighted courts for tennis. European Facial A classic facial used for deep, thorough cleaning, toning, steaming, and stimulation. Treatment focuses on pressure points, removal of dead cells, a masque and moisturizing for all skin types. Your hands and feet rest in heated gloves and booties during the facial. Makeup Makeup Consultation/Application. Become your own makeup artist! During each step of the makeup consultation, you will be learning how to look your best through individualized techniques designed to compliment your particular needs and features. Massage Swedish Massage: The massage can be either stimulating or sedating, depending on the rhythm and the strokes and manipulations used as the therapist works all major muscle groups. Hydrotherapy An underwater massage with aromatic oils and 47 high-pressure jets to relieve sore muscles and promote relaxation, massaging both deep and surface tissues.
