Summer On The Hill 2015 Application
Transcription
Summer On The Hill 2015 Application
SUMMER ON THE HILL JULY 12 - JULY 16, 2015 On the campus of Trinity University San Antonio, Texas W Experience independence in a College Setting, Improve Social Skills and have fun! Join us in July for a unique opportunity to experience independent living, forge new friendships, and have fun. Summer on the Hill is a residential /college living experience designed for persons 18 - 26 who: 1) Have Aspergers / AU or mild developmental disabilities 2) Are emotionally and physically well 3) Whose behavior is within acceptable guidelines Our mission is to further the progress of appropriate development, and to aid in the improvement of self-esteem, socialization, and independence in a safe, supportive, and FUN environment. Participants will live on campus in private dorm room with bathroom shared with suitemate In resident student mentors (Trinity Department of Education student volunteers) who will also facilitate the structured activities and social interactions The staff/participant ratio will be 1/6 The majority of the activities will be held on campus Meals will be provided in the dining hall Social Skills Drone session Nutrition Games Yoga Self Defense Training sessions for AU / IDD Karaoke Swimming Art/Drawing Social Networking Field Trip Goal Writing Money Management Interview skills Ideal candidate for this program will have: A desire to be independent A desire for social interaction A desire to experience college life The ability to try new things The ability to tolerate changes in routine The ability to accept the differences of others APPLICATION DEADLINE: June 5, 2015 (Space is Limited) Cost: $900 (includes meals, housing, programming, but not linens) Deposit: $100 required with application and will be applied to the program fee. Contact: Karen Pumphrey at (210) 490-4300 or email: [email protected] Application process will include an applicant interview Download application from website: www.arc-sa.org Sponsored for young adults ages 18-26, by The Arc of San Antonio and the Education Department of Trinity University Summer On The Hill 2015 Application Application deadline: June 5, 2015 Space is limited Application Process: 1. Return application and deposit to: SUMMER ON THE HILL c/o The Arc of San Antonio 13430 West Avenue San Antonio TX 78216 2. Schedule an interview: After your application is received, we will contact you to schedule an interview for the prospective participant Applicant Information Last Name____________________________________ First Name_____________________________________ Preferred Name_________________________ Address______________________________________________ City_____________________ State ______________ Zip ____________Phone ___________________________ Cell Phone_____________________ Email____________________________ Date of Birth__________________ Primary Diagnosis/Disability____________________________________________________________________ Gender □ Male □ Female Adult Shirt Size □ XS □ S □ M □ L □ XL □ XXL □ XXL Age ________ Height_________ Weight____________ Parent/Guardian Information Name_____________________________________ Relation to Student________________________________ Address________________________________________ City____________________ State______________ Zip_______________ Day Phone________________ Evening Phone ________________ Cell Phone______________________ Email ____________________ Emergency Contact Person #1 (This person must be available during session) Same as Parent/Guardian? □ yes □ no (if no please complete the information below) Name_____________________________________ Relation to Student____________________________ Address___________________________________ City____________________ State_______________ Zip_______________ Day Phone________________________ Evening Phone ______________________ Cell Phone______________________ Email _______________________ Emergency Contact Person #2 (This person must be available during session) Name_____________________________________ Relation to Student____________________________ Address___________________________________ City____________________ State _______________ Zip_______________ Day Phone________________________ Evening Phone ______________________ Cell Phone______________________ Email _______________________ The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org Page 1 Summer On The Hill 2015 Application Applicant Information (continued) Please indicate the most recent educational program or residential care environment in which the applicant has participated. Elaborate as needed to illustrate achievements and/or to identify areas for improvement. Continue on additional sheets if necessary. Name of school or program____________________________ Dates/years attended ___________________ If applicant is not currently enrolled in this program, please explain the reason for leaving: __________________ ____________________________________________________________________________________ Briefly describe the applicant’s overall experience with this program (strengths, areas for improvement, etc) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Hobbies: ___________________________________________________________________________ Favorite sports and athletics: __________________________________________________________ Level of participation in the sports listed above: __________________________________________ Favorite forms of entertainment: _______________________________________________________ Assistance/Guidance needed for any recreational activities: ________________________________ ____________________________________________________________________________________ Please describe the applicant’s reading, listening, and speaking ability: _______________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ If you answer Yes to any of the questions below, please attach an explanation Has applicant ever been convicted of a crime? Does the applicant have any pending criminal charges? Does the applicant have a history of alcohol abuse? Does the applicant have a history of drug abuse? The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org □ yes □yes □yes □yes □ no □no □no □no Page 2 Summer On The Hill 2015 Application Name of Applicant__________________________________________________________ Chronological Age___________________________ Mental Age ______________________ Diabetic □ Yes (see eating/diet section) □ Insulin Dependent □ No Eating/Diet □ Diabetic Diet □ Special Diet □ No help needed at meals Food must be: □cut □ chopped □mashed □pureed □ Camper must be fed □ G – tube □ Retainer □ Braces □ Dentures Allergies □ None □ Yes (list below) □ Epi-Pen Food:_____________________________________ Medicine:__________________________________ Other:____________________________________ _________________________________________ Seizures Diagnosis: Please list all (ex. Seizures, asthma, diabetes, MR, Psychosis, etc) 1.________________________________________ 2.________________________________________ 3.________________________________________ 4.________________________________________ 5.________________________________________ Medications □ No Meds □ PRN meds only Medication Dose Time ___________________ ________ ___________________ ________ ___________________ ________ ___________________ ________ ___________________ ________ ___________________ ________ **attach additional sheet if needed** ______ ______ ______ ______ ______ ______ □ Student can administer medication independently □ Student needs reminder, but can administer independently □ None □ Regularly □ one or two as child □ currently controlled with medication □ Student needs help administering medication Type(s): ____________________________________ Date of Last Seizure: __________________________ Usual Frequency:____________________________ Usual duration of seizures: _______________ minutes Triggered by: ______________________________ Medication Policy All prescription medications that the student will bring should be recorded on this form regardless of whether or not he/she is administering independently. All prescription medication must be in the original prescription container and should contain only the amount of medication needed for the duration of Summer on the Hill. Exceptions to this policy will be considered on an individual basis. Ambulation □ Walks unassisted Walks using: □ walker □ crutches □ braces □ cane Wheelchair: □ manual □ electric – bring charger The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org Page 3 Communication Behavior Issues (i.e. stressed induced pacing) □ No problems □ Limited but can communicate daily needs □ Non-verbal Sign Language □ Yes □ No Vision □ Normal □ Glasses/Contacts □ Blind Triggered by: _______________________________ Suggested Strategies: __________________________ __________________________________________ __________________________________________ Activity Restrictions □ Yes □ No □ Normal □ Hard of Hearing □ Aids □ Deaf Explain: _____________________________________ ___________________________________________ Sleep Heat Tolerance Hearing □ No Problems □ Walks in sleep Usual bed time:______________ Awakes at: _________________ Personal Hygiene: Brush Teeth, Bathe, Toilet, Dressing □ Completely independent □ Needs some help with: ____________________ _______________________________________ □ Good □ Fair □ Poor □ Dehydrates Easily Swimming Knows How? □Yes □ No Ear plugs when swimming: □ Yes □ No Wanders □ Needs total help in all areas □ Yes □ No □ Occasionally Additional Instructions _______________________________________ _______________________________________ _______________________________________ Additional Equipment □ None □ CPAP/BiPaP □G-tube □Feeding Pump □ Baclofen Pump □ Other * Please note that we may not be able to accommodate G-tubes, feeding pumps, and Baclofen pumps Please Note: 1. Summer on the Hill is for individuals who are willing to participate in group activities. 2. Summer on the Hill is not appropriate for individuals requiring one-on-one supervision 3. Smoking is not allowed 4. Behaviors that disrupt the normal functioning of Summer on the Hill may result in the individual being dismissed and no refund of fees will be granted. Such behaviors include, but are not limited to: Wandering, running away Foul language, cursing Fighting Tantrums Refusal or inability to sleep Incontinence Sexual acting out The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org Refusal or inability to eat Self-injurious behavior Extreme hypochondria Throwing objects Emotional outbursts Inability to adjust to the Summer on the Hill program Willful destruction of property Page 4 Summer on the Hill 2015 Application Name of Applicant__________________________________________________________ Social Security Number______________________ Date of Last Physical Exam____________ Insurance Carrier_____________________________ Group Number__________________ Member Name_____________________________________________________________ Physician______________________________________ Phone _____________________ If Down Syndrome, stable for atlanto-axial subluxation (ASS) □ Yes □ No Most Recent cervical x-ray for ASS ______________________________________________ Immunization or Date of Illness Polio ___________ , type___________ Measles_____________ HIB________________ Diptheria/Pertussis/Teatnus_________ Rubella ________________________ Permission to Give Over-The-Counter (OTC) Medications as Needed Please initial each medication /or generic equivalent that may be administered to your student. Write “No” beside any medications you do not wish administered. NOTE: You must have a physician’s written orders for any OTC medications to be given on a regular, scheduled basis. ______ Benadryl ______ Midol ______ Cortaid (skin cream) ______ Emetrol (nausea) ______ Pamprin ______ Pepto- Bismal (upset stomach) ______ Ibuprofen ______ Robitussin (cough) ______ Imodium (diarrhea) ______ Sudafed (congestion) ______ Lanacane ______ Tylenol (acetaminophen) ______ Dulcolax ______ Maalox (heartburn) ______ Other:_________________ Medication Policy All prescription medications that the student will bring should be recorded on this form regardless of whether or not he/she is administering independently. All prescription medication must be in the original prescription container and should contain only the amount of medication needed for the duration of Summer on the Hill. Exceptions to this policy will be considered on an individual basis. The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org Page 5 Permission/Release Form Please initial each statement Medical ______ Permission to Obtain Medical Treatment: I give my consent by signature below for medical treatment to be obtained for my child/ward/self by a representative of Summer on the Hill in the event I (or my designee) am unable to. ______ Permission to share Medical Information: I authorize the Summer on the Hill staff and volunteers to share, without restriction, my camper’s health information and medical records with any person (whether or not affiliated with Summer on the Hill) as may be reasonably necessary in order to facilitate the care of my camper. ______ Prescription Medication Policy: I affirm that I have read the policy concerning prescription medication. ______Agreement to Pay for Medical Treatment: I understand that in the event of a medical emergency affecting my self/child/ward, EMS may be called and my self/child/ ward may undergo hospitalization and/or treatment. I agree to assume all costs associated with such summoning of emergency medical care, hospitalization, and treatment, and I hold Summer On The Hill, Directors, and volunteers harmless for any liability, medical or financial arising from such. Transport for Off campus Activities and Emergency Transport _____ Consent/Permission to participate in off campus activities that are specific to the Summer on the Hill program. ______ Consent/Permission for Summer on the Hill staff to transport the participant to off campus activities specific to the Summer on the Hill program ______ Consent/Permission for Summer on the Hill staff to transport the participant in the event of a medical, facility, environmental, or natural disaster. ______ Consent/Permission for Summer on the Hill staff to transport the participant in their personal vehicle for off campus activities specific to the Summer on the Hill program or in the event of a medical, facility, environmental, or natural disaster. The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org Page 6 Permission/Release Form (continued) Please initial each statement Photographs/Videos ______ Consent/Permission for photos or video to be taken during the course of Summer on the Hill for the purpose of compiling a scrapbook/DVD to share among the staff and students. ______ Consent/Permission for photos or video to be used by Summer on the Hill and The Arc of San Antonio to portray or promote Summer on the Hill activities. ______ Consent/Permission for the student’s first name to be published in conjunction with photographs or video. (Last names will not be published.) Release of Confidential Information _____ Consent/Permission for the participant’s confidential information to only be shared with the Summer on the Hill staff for programming purposes only. I,________________________________________________________ , guarantee that the information on this application is accurate and hereby release and forever discharge Summer on the Hill and The Arc of San Antonio, its members, employees, and volunteers from any liability, suit, claim, or demand, whether for personal injury to myself or members of my family including minor children, or for property damage which result from any participation in the camping session. Student Signature_________________________________ Date_____________ Parent/Legal Guardian_____________________________ Date_____________ The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org Page 7 Summer on the Hill Behavior Checklist Each applicant will be evaluated on an individual basis. Behaviors listed below that occur with enough frequency to disrupt the normal functioning of the program may result in dismissed and no refund of fees will be granted. Yes 1. Wanders off or runs away 2. Needs help to feed self 3. Throws Objects 4. Emotional Outbursts 5. Tantrums 6. Physically fights with others 7. Injures self 8. Willfully destroys property 9. Bites, Scratches, kicks 10. Foul language/cursing 11. Continually complains of unfounded illness 12. Hallucinates to the point of dysfunction 13. Needs assistance for toileting needs 14. Frequent insubordination 16. Difficulty working with peers 17. Needs one-on-one supervision 18. Demonstrates sexual advances toward others 19. Taunts or bullies others ____ No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Explanation for any of the above that were answered “yes”: _____________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I understand that students unable to meet behavior criteria will be dismissed from the program and that program fees will not be refunded. Applicant’s Signature________________________ Parent/Guardian___________________________ The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org Date ____________________ Page 8 Summer on the Hill 2015 Application Payment Information Cost: $900 (A $100 deposit required with application and will be applied to the program fee. The deposit will be returned to those that we are unable to accommodate the student this year). Total fee must be paid no later than July 3, 2015. Check (make all checks payable to: The Arc of San Antonio) □ I have enclosed a check in the amount of: $100 deposit □ I have enclosed a check in the amount of: $800 total fee Credit Card Information □ I authorize my credit card to be billed in the amount of: $100 deposit □ I authorize my credit card to be billed in the amount of: $800 total fee Please charge my: □ VISA □MasterCard □ Discover □ American Express Name as listed on card: ______________________________________________________ Account #:_______________________________ Expiration Date:___________________ Signature:________________________________________________________________ Final Payment is due by July 3, 2015 NO refunds will be made after July 8, 2015 I would like to donate to Summer on the Hill : □ $10 donation □ $20 donation □ $50 donation □ $100 donation □Other: $_______ Please contact us at (210)490-4300 with any questions The Arc of San Antonio (210) 490-4300 ♦ www.arc-sa.org Page 9