Has the camper attended CNIB Lake Joseph Centre … · Web viewIndicate any strategies that are used to provide medication(s) to your camper. Include information about medications

CNIB Lake Joseph Centre – 2018 Youth Program Application Lake Joe is excited for the 2018 season with innovative programs and new activities being offered! We are committed to providing safe, fun and life-changing opportunities for our guests.

This summer we will be offering the following youth programs:

Summer CampThis exciting program is open to CNIB clients and their siblings, ages 8-17, from across Canada. Campers will have opportunities to learn new skills while developing confidence and independence in a safe and supportive environment.

Date: Monday, July 2-Friday, July 6, 2018 Cost: $450.00

Leaders-in-Training (LIT)Youth with vision loss who are 16-19 are invited to join our LIT (Leaders-in-Training) program. This unique program empowers youth to take an active role in camp life and become successful, positive leaders in our community.


Camp AbilitiesThis goal-based, pre-para Olympic program is aimed at specialized athletic development. Our aspiring athletes aged 8-17 will work with skilled experts and instructors who provide one-on-one coaching and support to help guide participants to achieve their performance goals. Specialties this year include triathlon and sailing.


PLAY through Sports & Rec (NEW for 2018!)Our new PLAY (Pushing Limits for Active Youth) program will have you getting active and discovering new sports at Lake Joe! Youth ages 8-18 will have the opportunity to try a number of different sports in this multi-sport experience.


1For any questions regarding this application please email [email protected] or call 705-375-2630

mailto:[email protected]

WILD (NEW for 2018!)New for this year, 10 participants (ages 15 – 19) will get to join us for this exciting 2-week adventure program! The WILD (Wilderness Immersion for Leadership Development) program will have participants working on tangible hard skills like camping, canoeing, hiking, outdoor cooking and orienteering, in preparation for a multi-day camping trip in Algonquin Park, white-water rafting on the Ottawa River and traversing high atop the forest along a treetop trekking course. Campers will also have the opportunity to work on leadership skills like communication, conflict resolution and facilitation to achieve their personal leadership goals.

Date: Monday, July 23- Saturday, August 4, 2018 Cost: $1200.00

Transportation is included and from the following locations:

Toronto – Costco: 100 Billy Bishop Way, North York, ON Toronto – Airport, Terminal 1: 6301 Silver Dart Dr., Mississauga, ON Hamilton - CNIB office: 115 Parkdale Ave S, Hamilton, ON Brantford - W. Ross MacDonald: 350 Brant Ave, Brantford, ON Ottawa – McDonalds, Billings Bridge Plaza: 2277 Riverside Dr., Ottawa, ON Kingston – Sport Check, Cataraqui Centre, 945 Gardiners Rd, Kingston, ON Sudbury – Tim Hortons, Canadian Tire Plaza: 2259 Regent St, Sudbury, ON

Financial assistance is available. Contact the office for more information.

Please help us to get to know you, your needs and your preferences by completing and returning the following nine (9) forms along with payment to Lake Joe by June 1st, 2018. To the attention of Sanda Rimay, Guest Services Manager.Registration Forms1. Camp Session and Camper

Information2. Transportation 3. Medical Information4. Assistance, behaviours and

personality

5. Dietary Information6. Accommodation Requests7. Consent & Release8. Promotional Consent (optional)9. Payment Form

We look forward to reserving your spot at beautiful Lake Joe! CNIB Lake Joseph Centre4 Joe Finley WayMacTier, ON P0C 1H0Phone:1-705-375-2630 or 1-877-748-4028 Fax: 1-705-375-2323Email : [email protected]




1. CAMP SESSION AND CAMPER INFORMATION

Please use a separate form for each camper.

SUMMER CAMP WEEK, $450 – Monday, July 2 to Friday, July 6, 2018(For campers ages 8-17 who are blind or partially sighted and their siblings)

LIT (Leaders-in-Training), $450 – Monday, July 2 to Friday, July 6, 2018(For youth turning 18 this calendar year who are blind or partially sighted)

Camp Abilities, $450 – Monday, July 23 to Friday July 27, 2018(For campers ages 8-17 who are blind or partially sighted)

PLAY through Sports and Recreation, $450 – Monday, July 23 to Friday July 27, 2018(For campers ages 8-17 who are blind or partially sighted)

WILD*, $1200– Monday, July 23 to Saturday, August 4, 2018(For campers ages 15-19 who are blind or partially sighted)*This program requires an additional form, interview and has very limited registration.

Has the camper attended CNIB Lake Joseph Centre before?Yes # of years: Year of the last camp attended: No

Camper Information and Primary Contact Information



First Name Last Name

Gender Age Date of birth

(DD/MM/YYYY)

Health Card # Version:

Address City

Province Postal Code

Email Phone ( )

T-shirt Size (Adult/ Youth and Small/ Medium/Large)

Parent/ Guardian Information and Additional Contact (if parents can't be reached)

How did you hear about the CNIB Lake Joseph Centre? (Please check appropriate box)

Returning Camper Local CNIB Office School Friend Newsletter Other:

2. BUS TRANSPORTATION

Location & Meeting Spot Going to Leaving camp


Full Name Relation Phone number or email (if different than above)1

2

3


campToronto Airport -Terminal 1Yorkdale CostcoSudbury – Canadian Tire PlazaHamilton -CNIB OfficeBrantford -W.Ross MacDonaldOttawa -Billings BridgeKingston -Cataraqui Centre

No transportation is needed

Authorized Pick-Up


Full Name Relation Home Phone Cell Phone ( ) ( )


3. MEDICAL HISTORY

The information contained on this form is considered private and will be available to the Wellness Staff and relevant Camp Staff. This information is meant to assist us in providing the best possible care for all campers in our program. Please provide us with as much detail as possible and be specific when answering all questions. My camper is subject to, or has been diagnosed with:

ADD/ADHD Epilepsy/SeizuresAsthma Frequent coldsAutism Spectrum Disorder Heart conditionDiabetes Kidney Disease

Ear infections MigrainesOther (Please let us know if your child has any other diagnosis not listed above):

Immunization: Is your camper's immunization up to date (Diphtheria, Pertussis, Tetanus, Polio, MMR)?Yes No If NO, please elaborate: Year of last Tetanus (DPT, DT):

Is your camper undergoing any form of treatment for any physical or emotional illness, condition or injury that may affect or limit participation in camp activities?Yes No If YES, please elaborate:

Has your camper recently been hospitalized?Yes No Date of Hospitalization: Reason: Does your camper have any allergies (food, environmental, drugs/medication, etc.)? Yes No If YES, please elaborate (attach additional pages if necessary):

Type of reaction (e.g. Anaphylaxis, rash, etc.):

Does your camper carry an EpiPen or any allergy medication?Yes Where: No



MedicationsPlease indicate the medications the child will take at camp. ALL medication(s) administered at camp must be written on this form. Please add additional pages if necessary.

Please note: All medication/other supplies necessary for use while at camp will be stored in

the Wellness Centre and the administration of medication will be monitored by Wellness Staff as directed by your physician.

Send all medications in their original packaging, properly labelled with your child's name. The medication must include the pharmacy label with patient information.

Indicate any strategies that are used to provide medication(s) to your camper. Include information about medications used to prevent nausea and vomiting and pain management, if applicable.

If medication schedules change before the summer, please inform us of the changes as soon as possible.

Our Wellness Centre does not carry over the counter medications (OTC) such as Acetaminophen, Ibuprofen, Gravol, etc. Please bring any OTC medications required.


Drug Name and Strength Dose Frequency Time of Day

Additional Information:


4. ASSISTANCE, BEHAVIOURS AND PERSONALITY

Level of Assistance for your childIndependent Some

Assistance Total CareDaily Care (brushing teeth, combing hair, dressing)MealsMedicationBathing/ShoweringToileting/BathroomDoes camper have problems with bed-wetting?

Yes NoIf the camper is female has she began her menstrual cycle?

Yes No*If YES to either of the above, please provide enough personal hygiene supplies (plus a few extra) for the length of their stay at camp.

CommunicationHow does the camper communicate?

Verbal Single Words Sign Language Non-verbal

Preferred format Large print Braille Other: please specify

First language:

Additional Information/Comments:

Sleep Behaviours (select all that apply)Difficulty falling asleep Sleeps with a light onDifficulty sleeping until morning Makes a lot of noise at nightWakes up easily during the night SleepwalksGets out of bed frequently during the night

Additional information/ comments:



Behavioural Concerns (select all that apply)Homesickness Sensitive to LightRunning Risk to OthersAttention Seeking Risk to SelfSensitive to Noise Easily FrustratedPunching/Hitting

Triggers and signs of escalation:

Best way to support distressed camper:

Has camper been away from home before? Yes NoIf Yes, how long: Has camper done overnight camps before? Yes NoDoes your camper actively participate in group activities?

Yes No

Additional information/ comments:



5. DIETARY INFORMATION Please describe camper’s eating habits: Fussy Average Hearty

Please check all the apply.

Dietary RestrictionsVegetarian Gluten FreeNo Pork Dairy FreeVegan Diabetic Diet

Other (please specify)

Food AllergiesNuts MilkGluten EggsSeafood TomatoesOther (please specify)

6. ACCOMMODATION REQUESTSPlease list anyone you would like to have as a roommate. If you have no preference, please leave blank, and a roommate will be assigned.

First choiceSecond choiceAnyone you would NOT like to have as a roommate

Lake Joe will endeavour to accommodate all roommate requests from our guests. However, due to demand, Lake Joe cannot accommodate specific room or cabin requests. Our goal is to ensure as many guests as possible have an opportunity to enjoy Lake Joe.



7. CNIB LAKE JOSEPH CENTRE CONSENT AND RELEASE FORM (Required)I, _______ , voluntarily consent to participate (or to have my child, ____ , participate) in the Canadian National Institute for the Blind ("CNIB") Lake Joseph Centre program.

GeneralI am aware that transportation to the CNIB Lake Joseph Centre will be offered as part of this program and CNIB staff may be required to transport me or my child in a vehicle owned by CNIB.

I understand and accept that there is a risk, by participating or having my child participate in the program, that I, he or she could suffer loss, damage, injury (including death) or expense. In consideration of CNIB allowing me or my child to participate in the above program, I agree to hold harmless and release CNIB, its partners, associates, officers, employees and volunteers from any loss, damage, injury or expense that I or my child may suffer due to any cause whatsoever.

MedicalShould it be necessary for my child to have medical treatment while participating in these field trips, and it is not possible to contact me, I hereby give CNIB permission to use its judgment in obtaining medical services for my child, and I give permission to the physician selected by CNIB to render medical treatment deemed necessary and appropriate by the physician.

By signing this form, I certify that I have read this form fully and understand it, and I have signed this form voluntarily.

Signature of Parent or Guardian Date



8. PROMOTIONAL CONSENT FORM FOR INDIVIDUALS (Optional)Purpose: to acquire new promotional material to help promote our charitable objectives and to raise awareness of the programs and services we provide to our clients and community.

Authorization • I understand that I am providing promotional material to assist CNIB, a not for profit charitable organization. • I understand in giving my time to CNIB that I will receive no monetary compensation for participation in any promotional activities. • I give consent for information, photographic images and/or video and sound recordings (‘promotional material’) to be used by CNIB. • I give consent for all or part of the material to appear in any of the wide variety of formats and media now available and that may be available in the future, including but not limited to print, broadcast, CD-ROM and electronic/online media. • I give consent to the promotional material being shown to appropriate professional staff and the general public. • I understand that this agreement does not expire. • I understand that I may withdraw my consent and void this agreement at any time by contacting the person below.

I agree with the above statement and confirm my consent by signing below.

Signature of Parent or Guardian Date



9. PAYMENT INFORMATION

A minimum deposit is $50.00 per camper is required to secure a spot. There is no early bird rate for these programs. Please select payment method below. Please do not send cash in the mail.

Please indicate the method of payment: Credit Card Money Order Cheque

If paying by credit card, please indicate:

American Express MasterCard Visa

I hereby authorize CNIB to charge the credit card listed below.

Amount

Credit card # 3-Digit Security # (back of card)

Expiry-Month/Day Postal Code

Signature of Cardholder Date

Please note: Cheques or credit cards with insufficient funds will result in a $35 fee. Incidentals such as room damage, medical supplies, costs, etc. incurred by the guest will be charged to the above card.

Cancelation PolicyIf you cancel your spot on or before June 1, 2018, you will receive a full refund with the exception of the deposit amount. If you cancel your spot after June 1, 2018, a refund will not be issued. If there are extenuating circumstances you may contact the office. All cancelations must be submitted in writing.



Documents

Has the camper attended CNIB Lake Joseph Centre … · Web viewIndicate any strategies that are used to provide medication(s) to your camper. Include information about medications