Aquatic and Motor Therapy Program · of Toledo-Perceptual Motor Development Clinic (1987-1997) and Purdue University’s Pete’s PALS (2007-2009). Flynn’s specialty is in the area

Spring 2020 FitCatZ Participants Application Packet

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Spring 2020 Application

Aquatic and Motor Therapy Program

6 Week Program

Time: 3:30-5:30 PM Dates: February 26th, March 4th, 11th, April 1st, 8th, 15th Place: Ashley Hall School, 172 Rutledge Ave, Charleston, SC 29403 Fee: $95.00 for the six-week program, make checks to the College of Charleston

Applications Due: February 10, 2020

Susan M. Flynn | College of Charleston | School of Education, Health and Human Performance | 86 Wentworth Street, room 235 | Charleston, SC 29424 | 765-414-3837 | [email protected]


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FitCatZ Program Overview The FitCatZ program is an aquatic and motor therapy program designed for children with special needs. The program’s goal is to help participating children become efficient movers in a fun and safe environment. Each child in the program is assigned a trained volunteer student clinician who will work one-on-one with the child during the aquatic and motor program. FitCatZ is supported by the College of Charleston Department of Teacher Education and the First Year Experience Program and is conducted at Ashley Hall School.

Each child's program will be tailored to their needs and abilities and may include:

• Physical fitness activities to improve muscular strength, endurance and flexibility • Sensory motor activities • Fundamental motor patterns and sport skills • Body awareness and spatial orientation • Swimming and water safety skills

Participant Eligibility: FitCatZ is open to children with a range of physical, intellectual, behavioral, and emotional special needs ranging in age from 2 to 18 years old. We are willing to work with parents to accommodate specific concerns and can provide additional assistance for children with specific needs.

Supervision The program is being administered by Program Director, Susan Flynn. Susan is a Senior Instructor at The College of Charleston in the School of Education, Health and Human Performance. Flynn has organized and conducted similar successful programs at The University of Toledo-Perceptual Motor Development Clinic (1987-1997) and Purdue University’s Pete’s PALS (2007-2009). Flynn’s specialty is in the area of adapted physical education. All phases of the program will be monitored and supervised by the Program Director, the Physical Therapist. Aquatic Specialist and the Sensory Integration Specialist. Role of the FitCatZ Clinician: Children participating in FitCatZ will be paired one-on-one with a trained undergraduate or graduate volunteer student clinician. The clinicians are recruited from local graduate and undergraduate education and therapy disciplines and are volunteers whom have shown an eagerness to work in the program and who demonstrate a willingness to learn and accept an educational challenge to motivate and teach children and youth with special ne. Interested

Sunday, 1, 2008 through

Saturday, 7, 2008


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volunteers are interviewed and agree to the commitment of the FitCatZ program. Each child is strategically paired with a clinician based on the clinician’s experience and the child’s specific needs. Throughout the program, clinicians will evaluate children’s aquatic and motor development needs and will structure individualized instruction in order to help them progress toward goals and objectives developed by the clinicians in concert with parents and children. Group Leaders Group Leaders are graduate or experienced undergraduate student volunteers who have been chosen to assist with the administration of the program. Group Leaders are not paired with a specific child, rather they assist with all of the FitCatZ children and clinicians assigned to their group. Group Leaders are assigned to work with 4-6 clinicians and their FitCatZ buddy to:

• Assist with parent communication and attendance • Manage drop off and pick up times with the children and parents • Assist with child evaluation and goal setting • Assist with weekly motor and aquatic lessons • Assist with the set up and tear down of equipment used in the program • Evaluate lesson plans, Body Skills Assessment Report and Final Case Report.

Aquatic Specialists Certified Water Safety Instructors will be training the clinicians for aquatic safety and developmentally appropriate swimming instruction. In addition, they will be teaching swimming skill instruction during the aquatics portion of The FitCatZ Program.


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FitCatZ Spring 2020 Program Schedule The specific program dates are: Dates: February 26th, March 4th, 11th, April 1st, 8th, 15th Place: Ashley Hall School, 172 Rutledge Ave, Charleston, SC 29403 Program Schedule: 3:30-3:40 p.m. Parents drop off children 3:30-5:15 p.m. Motor and Aquatics Therapy 5:15-5:30 p.m. Pick up Application Process: Parents interested in registering their child for the FitCatZ Program should complete the attached application packet and send it to Susan Flynn at the address provided below along with a check for $95.00 made payable to The College of Charleston. In order to ensure a spot in the program, application materials must be returned by Monday, February 10th, 2020. Applications will be accepted in the order in which they are received. There are a limited number of spots in the program, so we recommend interested families submit completed paperwork as soon as possible. Please contact Susan Flynn (information below) for questions or additional information. Call Susan Flynn for the application. (765-414-3837) Parent-Clinician Communication: In order to help personalize the FitCatZ program to the needs of the children, we encourage our clinicians and group leaders to foster a positive relationship with parents. As a part of this relationship, we will ask our group leaders to communicate with parents on a regular basis and will provide you with their email address so you can contact them prior to the start of the program. This pre-program communication is critical as it helps clinicians to plan for the first session and outline the objectives for the program.


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Preparing for FitCatZ Application Materials: To apply for FitCatZ, please be sure to complete the following

• Participant Application Form • Technology and Information Release Form • Parental Authorization Form (which includes a physician’s signature or recent school

physical form) • Non-Parental Pick-Up Authorization • Waiver, Release, and Hold Harmless Agreement • Check to The College of Charleston ($95.00)*

In order to successfully apply for the program, each of these forms must be completed and returned, along with payment, to: Susan M. Flynn College of Charleston School of Education, Health and Human Performance 86 Wentworth Street, room 235 Charleston, SC 29424 c. 765-414-3837 [email protected] What is needed for FitCatZ: In order to be prepared for the program, children should bring the following items each session:

• Backpack/duffel bag to hold belongings with the child’s name on it • Wear Sneakers or tennis shoes • Comfortable clothes for playing in the gym • A swimsuit and towel with the child’s name on it • Rubber pants for swimming if needed • Ear-plugs or swimming goggles if needed • Extra change of clothes with child’s name on them


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Spring. 2020 Participant Application Form General Information:

Child’s Name: ___________________________________T-Shirt Size: ________ Youth or Adult

Child’s Age: Date of Birth: Male / Female

Address: ___________________________________________________________________________

City: _____________________________________ State: ______________ Zip Code: __________

Parent Information:

Mother’s Name: __________________________ _________________________________________

Email Address: ___________________________ Phone Number: __________________________

Father’s Name: ___________________________ _________________________________________

Email Address: ___________________________ Phone Number: __________________________

Person to contact in case of emergency: _______________________________________________

Phone number(s) of the person who is to be contacted: __________________________________

School your child attends:

Allergies, including food allergies:

Communication: How does your child communicate? Verbal Sign Language See Sign Language Board Electronic Device

Does your child use a hearing aid? ___ Yes ___ No

(If yes, please provide a container for them while swimming and daily care instructions.)

Swimming Considerations: Does the child enjoy being in the water? Yes No Describe the child’s swimming ability and/or provide additional information as appropriate: ______


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Child’s Name: _________________________________________ Date: ___________

Specific Needs Information: (Please attach another page if necessary) What is the name of the child’s disability/specific need? Please provide a detailed explanation of the disability and/or specific needs (Additional information can be provided on the back on this sheet or an attached sheet): Provide additional information to help clinicians plan the weekly lessons (likes, dislikes, movement capabilities, specific needs, etc.) Attach additional information to help us know your child best. _____________________________________________________________________ I.E.P. Motor goals (if any): ____________________________________________________________ Does your child have any contraindications (i.e., things he/she should not do) in a physical activity setting? If so, please explain: Behavior Issues: Describe any behavior challenges your child may have and effective discipline techniques:

Does your child have aggressive behavior and/or Oppositional Defiant Disorder (ODD)?

Yes No _____

If so, how is it most commonly displayed:


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TECHNOLOGY INFORMATION & RELEASE FORM The future of the FitCatZ Program will be determined in part by the successful promotion of the program. We request your assistance in promoting the program by granting permission to use any photographs, videotape or audiotape of your child for our publications, videos or web pages. Please review and sign below to indicate your consent of our use of the photographs, videotapes or audiotapes.

I hereby authorize and consent to the use and reproduction by the College of Charleston and FitCatZ Program of any and all photographs, video tape recordings, or audio tape recordings in which my child appears. I understand I will not receive payment for the photographs, video tape recordings, or audio tape recordings, and the photographs, video tape recordings or audio tape recordings will not discredit or distort my child in any way. All negatives and positives, and tapes, together with the prints shall be solely the property of the FitCatZ Program.

Student’s Name:

I certify I am the parent or guardian of the child named above and give my consent to the use of my child’s name and likeness for promotional activities as described above.

Parent/Guardian Name:

Parent/Guardian Signature:

Date:


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Pick-up Permission Form For the safety and security of your child, we request a list of eligible “Pick-up People” who you authorize to pick up your child from the program each night. For your child’s safety and security, only these individuals authorized by you as the parent/guardian will be allowed to pick up your child from FitCatZ.

THIS FORM ONLY NEEDS TO BE COMPLETED IF THE PARENTS/GUARDIANS WHO COMPLETED THIS REGISTRATION PACKET MAY NOT BE PICKING UP THE CHILD. We will ask for identification from EVERYONE (including parents/guardians) who picks up a child each night, so please inform anyone who may be picking up your child that they will need photo identification (and so will you!) If you have any questions, please contact Susan Flynn ([email protected] or 765-414-3837).

Child’s Name:

Pick up Person #1:

Relationship to Child: Telephone #:

Driver’s License #: Issuing State:

Pick up Person #1:

Relationship to Child: Telephone #:

Driver’s License #: Issuing State:


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College of Charleston Medical Authorization for Treatment of a Minor (persons under 18 years)

I request and authorize the College of Charleston FitCatZ staff, Charleston Ambulance Service, and Ashley Hall School, the Arthur Christopher Center, medical personnel, agents, and employees of aforementioned entities (collectively “FitCatZ”) to coordinate or provide necessary medical care advisable for the health of my child. I understand and agree that FitCatZ assumes no responsibility for injury or damages, which may arise out of or in connection with such authorized necessary medical care. I have adequate health insurance to provide for and pay for any medical costs that may arise as a result of injury to my child. I understand that FitCatZ is not obligated to provide for any of medical or medication needs or insurance and that I assume all risk and responsibility for those needs. I also understand that, as a result of my child’s participation in this program, it will be necessary for supervisors, clinicians, and others involved with the program to have access to relevant medical information pertaining to my child, and I authorize the use and disclosure of my child’s medical information to promote a safe and healthy experience for my child. Further, I hereby grant permission for my child (name) to attend the College of Charleston FitCatZ Program by signing below. A signature from one or both parents/legal guardians and a witness signature is required. Signature Parent/Legal Guardian (required):

Signature Parent/Legal Guardian/Witness (required):

Signature Parent/Legal Guardian (required):

Signature Parent/Legal Guardian/Witness (required):


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PHYSICIAN APPROVAL (required for each child/year for current changes) I have examined (child’s name) and found him/her to be healthy to attend and participate in activities during the FitCatZ Program. Medical Conditions:

Current Medications:

Allergies:

Date of Last Tetanus Shot: (If unknown, child may be required to

obtain a tetanus shot if injured)

Physician’s Name: Phone Number:

Physician’s Signature:

*****************************************************************************************************************

Name of Insurance Group____________________________________

Policy No: _____________________________________________

Emergency Contact: ___________________________ phone: ___________________________


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Waiver, Release and Hold Harmless Agreement In consideration of permission granted by the College of Charleston allowing participation in the FitCatZ aquatic and motor therapy program, which will occur during the semester and will be held at Ashley Hall School and/or the Arthur Christopher Center sponsored by the College of Charleston, School of Education, Health and Human Performance, Teacher Education Department. I (together with my parent or guardian, if I am under the age of eighteen or under a legal disability) represent, covenant and agree, on behalf of myself and my heirs, assigns, and any other person claiming by, under or through me, as follows:

1. I acknowledge that participating in the FitCatZ program involves certain risks and injuries, death, property damage or other harm could occur to me or others. Knowing the dangers, hazards, and risks of such endeavors, and in consideration of being permitted to participate in the Activity, on behalf of myself, my family, spouse, heirs, and personal representative(s) (the “Releasors”), I agree to assume all the risks and responsibilities surrounding my child’s participation in the FitCatZ program and the transportation to and from the FitCatZ program, and on behalf of myself and the Releasors I hereby release, waive, forever discharge, and covenant not to sue the State of South Carolina, the College of Charleston, Ashley Hall School, Arthur Christopher Center and their respective trustees, officers, agents, employees, volunteers, and any students acting as volunteers (“Releasees”), for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature that I may have or that may hereafter accrue to me or a Releasor, arising out of or related to the Activity, any act supplemental to the Activity, or for any occurrence while I am in transit to or from the premises where the Activity or act supplemental to the Activity is being conducted.

2. I further agree to indemnify and hold harmless the Releasees from and against any loss, liability, damage or cost, including court costs and attorneys’ fees, that the Releasees may incur arising from my participation in the Activity.

3. I have carefully read and reviewed this Waiver, Release and Hold Harmless Agreement. I understand it fully and I execute it voluntarily.

EXECUTED this day of , 20 .

THIS IS A LEGAL AGREEMENT AND INCLUDES A RELEASE OF LEGAL RIGHTS. READ AND BE CERTAIN YOU UNDERSTAND IT BEFORE SIGNING.

I AM THE PARENT OR LEGAL GUARDIAN OF THE STUDENT STATED ABOVE AND I AFFIRM THE TRUTH OF EACH REPRESENTATION MADE BY THE MINOR AND ON BEHALF OF THE MINOR AND ALL “RELEASORS,” AS DEFINED IN PARAGRAPH 1 ABOVE, I AGREE TO EACH AND EVERY TERM AND CONDITION OF THIS WAIVER, RELEASE, AND HOLD HARMLESS AGREEMENT. ___________________________________________________________________________________________ (Print) Parent or Guardian Signature Date

Documents

Aquatic and Motor Therapy Program · of Toledo-Perceptual Motor Development Clinic (1987-1997) and Purdue University’s Pete’s PALS (2007-2009). Flynn’s specialty is in the area