2016 camp alec application

Indian Trails Camp • 2016 Camp ALEC Summer Camp Application • of 13

2016 Summer Camp Application

Camper’s Name: __________________________________________________________________________________________________ Last First Middle

Address: _________________________________________________________________________________________________________ Street City State Zip

Telephone: (______)__________________ Male: _____ Female: _____ Birth Date: _____/______/______

County: ________________ Ethnic Background (optional): __________________ Has camper attended ITC before: Yes ___ No ___

Parents/Guardians Full Name: ______________________________________________________________________________________

Address (if different): ______________________________________________________________________________________________ Street City State Zip

Email Address: __________________________________________________________________________________________________ *No person shall be excluded from services because of race, religion, sexual preference, disability or national origin.

ContACt InformAtIon

SESSIon—CAmp ALEC

T-ShirT Size: Youth S M L Adult S M L (please circle one)

A 5 minute unedited video with examples of your child communicating may be requested, but is not required at this time.

Primary mode of communication at home: ___________________________________________________________________________

Primary mode of communication at school: __________________________________________________________________________

How does your child indicate “YES”? _______________________________________________________________________________

How does your child indicate “NO”? ________________________________________________________________________________

Is your child’s Yes/No response: ❑ Reliable ❑ Inconsistent

Approximate Language Comprehension Level: _______________________________________________________________________

Verbal Abilities: __________________________________________________________________________________________________

Does your child use any gestures consistently for communication? Please list: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Communications Systems: Check all that apply: ❑ Manual Communication Board ❑ Speech Generating Device

Device Name ____________________________________________________________________________________________________

Device page set (if applicable): ______________________________________________________________________________________________________________________________________________________________________________________________________


How does the child access the device? (Please explain): ______________________________________________________________

_________________________________________________________________________________________________________________

Direct Selection: _________________________________________________________________________________________________

Scanning: _______________________________________________________________________________________________________

Switch Type and Access Site: ______________________________________________________________________________________

_________________________________________________________________________________________________________________

Switch Accuracy (Estimate % Correct): _____________________________________________________________________________

Tendency to hit switch more than once: _____________________________________________________________________________

Briefly describe vocabulary organization of child’s device (e.g. # of pages or levels; # of pictures or words per overlay): _______

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_________________________________________________________________________________________________________________

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Is the device mounted to a wheelchair? ❑ Yes ❑ No

How long has the child had the device? _____________________________________________________________________________

When learning, my child works best in: ❑ 15-minute sessions ❑ 30-minute sessions

❑ Individual sessions ❑ Group sessions

❑ With 1-1 behavioral support ❑ With hand-over-hand support

Status of reading and writing skills:Knows most of the letters most of the time? ❑ Yes ❑ No

Interested and engaged during book sharing? ❑ Yes ❑ No

Books/subjects that are most interesting or motivating for your child: ___________________________________________________

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How does your child use their device? Check all that apply:

❑ Independently ❑ Answers questions only

❑ One word response ❑ WIth language models

❑ With verbal prompts ❑ Preprogrammed phrases/responses

❑ Builds own phrases/sentences ❑ Spells words/uses word prediction

❑ Has access to core volcabulary ❑ Initiates social exchanges

❑ Can signal if he/she needs help, please describe ________________________________________________________________ Would someone unfamiliar with your child’s customized pages be able to model language and help your child locate

volcabulary? _____________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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Please describe approximate reading level: __________________________________________________________________________

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Please describe how your child accesses books: _____________________________________________________________________

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Please describe how your child writes: ______________________________________________________________________________

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Please describe approximate writing level: __________________________________________________________________________

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What does attending Literacy Camp mean to you? ___________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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Please attach your child’s current IEP to this application.


I, ________________________________________, hereby affirm that I am a camper and that I am of lawful age and legally competent to sign this Release Agreement or that I am the parent or legal guardian of _____________________________________who is a camper and that I am lawful age and legally competent to sign this Release Agreement.

I give permission for me or my minor child to attend ITC and participate in all phases of the activities, including swimming, boating, and trips away from ITC. I am aware of the possible risk of injury or death to me or my child as a result of participation In the programs at ITC, and I acknowledge that by this Release Agreement neither ITC, nor its directors, instructors, agents or employees may be held liable for any injury to or death or, me or my minor child whether or not such injury or death result from the negligence of ITC or its directors, instructors, agents or employees. Wherefore, in consideration for ITC allowing me or my minor child to participate in its programs, I hereby agree to personally and fully assume all risks in connection with my or my minor child’s participation in ITC programs, and I release and discharge ITC and its instructors, agents and employees from any and all claims or causes of action, whether present or future, whether known, anticipated, which may be brought by me, my minor child, my family, estate, heirs or assigns arising out of any occurrences in connect ion with my child’s participation in ITC programs which may result in the injury or death of myself or my minor child, whether or not such an injury or death is caused by the negligence of ITC or is directors, instructors, agents or employees. Additionally, in case of any injury to me or my child, I give permission for ITC to secure medical and surgical treatment and provide routine, nonsurgical medical care for me or for my minor child, in my absence, while attending camp.

I give permission for me or my child to be photographed or videotaped in camp activities and allow ITC/Camp ALEC to use these photos for general promotional usage. It should be understood that any print utilized will be done so in a most respectful manner, and in no way shall be used to exploit an individual. I further state that I have signed this agreement voluntarily after fully informing myself of its contents.

____________________ _____________________________________________________________________________________________ Date Adult Camper or Parent/Legal Guardian

rELEASE AgrEEmEnt

EmErgEnCy InformAtIon

Unless otherwise requested, the parent/legal guardian listed below will be the first person contacted in the event of an illness or injury.

Parent/Guardian Name: ____________________________________________________________________________________________

Place of employment: _____________________________________________________________________________________________

Hrs reached: __________________________________________ Email: _____________________________________________________

Work phone: ____________________________________ Other Phone #: ___________________________________________________

Parent/Guardian Name: ____________________________________________________________________________________________

Place of employment: _____________________________________________________________________________________________

Hrs reached: __________________________________________ Email: _____________________________________________________

Work phone: ____________________________________ Other Phone #: ___________________________________________________ If parent/legal guardian cannot be reached, whom shall we contact (in order of preference)?

1) ________________________________________________________________(_______)_______________________________ Name Relation to Camper Phone # 2) _______________________________________________________________ _(_______)_______________________________ Name Relation to Camper Phone #

While camper is at ITC, parents will be: At home ___ On vacation ___

Can be reached at: __________________________________________________ _______(_______)______________________________ Name/Location Phone # Who will be picking camper up on outgoing day: ______________________________________________________________________ Name Relation to Camper


_____Cerebral Palsy _____Muscular Dystrophy_____Spina Bifida_____Multiple Sclerosis_____Rheumatoid Arthritis_____Epilepsy_____Arthrogryposis _____Osteogenesis Imperf. _____Visual Impairment

_____Autism/ASD _____Down’s Syndrome_____Other (please explain) ___________

__________________________________________________________________

_____Congenital Anomalies/Birth DefectsExplain in detail ____________________________________________________________________________________

_____CHI (Closed head injury)_____Mental Impairment

_____Mild (Cognitive Impairment)_____Moderate_____Severe

_____Other (please explain) ___________ __________________________________________________________________

CommUnICAtIonS ____No communication difficulties ____Verbalizes, may be difficult to understand ____Non-verbal, Yes/No Responses Only Explain_________________________________________________ _______________________________________________________ Explain communication board or system___________________ ______________________________________________________________________________________________________________Additional information that would be helpful________________ _____________________________________________________________________________________________________________________________________________________________________Is camper allergic to service dogs? Yes___ No ___

gEnErAL HEALtH InformAtIon Does camper have seizures? Yes___ No___ Frequency______________________________________________Please describe the seizures including length and severity ______________________________________________________________________________________________________________Common signs/conditions of seizure_____________________________________________________________________________ _______________________________________________________ Does the camper have allergies? Yes___ No ___ If yes please explain agent and reaction in detail ____________ _______________________________________________________

AMBULATION ___Crutches ___Walker___Wheelchair___Elec. Wheelchair___Scooter___Other:____________________________________________

EATING ___Special Cup ___Special Dish___Special Utensils___Plate Guard ___Other:______________________________________________________________________

OTHER___Hoyer Lift ___Toilet Commode___Communication Board ___Helmet ___Pace Maker___Other:____________________________________________

BRACING ___AFO___Hand Splint___Other:______________________________________________________________________

CAmpEr InformAtIon

CAMPER NAME:_____________________________________ BIRTHDATE:____ /____/___ SESSION(S)___________

MALE:________ FEMALE:________ NICKNAME, IF ANY:_________________________________________________________

DISABILIty

SpECIAL EQUIpmEnt tHAt CAmpEr WILL BE BrIngIng to CAmp

Check all applicable:


EAtIng ____Independent ____Needs only food cut & plate set ____Must be fed

AmBULAtIon ____Walks ____Independent ____Needs assistance* *Describe______________________________Depends on mobility device* *Describe ________________

DrESSIng & UnDrESSIng ____Independent ____ Need assistance with fine motor skills ____Total assistance

pErSonAL CArE InformAtIon Check any which camper will need assistance with ____Showering ____Shaving ____Teeth-Brushing ____Personal care menstrual cycle

toILEtIng____Wears Briefs____Independent ____Needs assistance* *Describe______________________________Special bowel treatment/program (describe)___________________________________________________________________ How often does camper have bowel movements:__________________________________________________________________

trAnSfErS Approximate Weight_________ ____Independent ____Can bear weight for pivoting ____Must be lifted Precautions that should be taken if any: ______________________________________________________ ______________________________________________________

BEHAVIor nEEDSDoes camper have any behavior problems?________________If yes, please:

Describe Frequency__________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ _________________

How might we best accommodate these behavior problems_______________________________________________________ _______________________________________________________

ADJUStmEnt to CAmp ____Has attended Indian Trails Camp before ____ If new to Indian Trails Camp, has the camper been to

another camp in the past Any known fears________________________________________

CABIn-mAtE rEQUEStS Please list any requests you have for cabin mates. We will try our best! 1)_____________________________________________________

2)_____________________________________________________

otHEr____Anything else that wasn’t mentioned above:___________________________________________________________________ _______________________________________________________ _______________________________________________________

ACtIVItIES of DAILy LIVIng


fInAnCIAL form

Camper Name: _________________________________________________________ Age: ___________ County: __________________

1. Complete the attached Level Determination form and submit with application. Check appropriate level below.

__LEVEL 1 Minimal Dependence $762 (6-days) + * $250 Literacy Portion

__LEVEL 2 Moderate Dependence $1,116 (6-days) + * $250 Literacy Portion

__LEVEL 3 Complete Dependence $1,536 (6-days) + * $250 Literacy Portion

* This portion paid for by the Alec G. Cunningham Foundation. If at any time after receipt of this form and camper application, the Camp Director and/or Health Director find the camper to require a different level of care than indicated, Indian Trails Camp reserves the right to change the level and fee accordingly. The camper and/or family will be notified if such change occurs.

2. Based on the above Level Determination, complete the following calculations.

totAL DUE BASED on tIEr $

$250 Literacy Fee paid for by the Alec G Cunningham foundation $ 0

- DEPOSIT* (non-refundable $100) Check #___________ or Credit Card (complete part 3 B)

BALAnCE DUE $________________

_______ I have a financial need and request scholarship funding (complete 4 below AND a scholarship application)

3. Complete A, B or C to indicate source of payment. If a scholarship is requested and granted, that amount will be deducted from the indicated payment option.

A. pArEnt/gUArDIAn or SELf WILL pAy In fULL By JUnE 15, 2016

B. CrEDIt CArD pAymEnt: _____VISA _____mAStErCArD SECUrIty CoDE__________ EXp _____/_____

Card Number ___________ - ___________ - _____________ - ______________ Zip Code __________________________________

Name as it appears on card __________________________________________________________ Ph # (______)_______________

Card billing address ____________________________________________________________________________________________

C. BILL orgAnIZAtIon:

Name:_________________________________________________________________________________________________________ Address:________________________________________________________________________________________________________

Ph # (______)_______________________ Fax # (______)_______________________

Attn: ______________________________________________ Amount to be paid: ___________________________________

Send bill: ________before (or) _______after session.


SCHoLArSHIp AppLICAtIon form

The Alec G. Cunningham Foundation is a small, nonprofit organization dedicated to providing campers with disabilities a rich camp experience while also adding the literacy component to this specialized week at Indian Trails Camp. Our goal is to reduce the cost of camp. Scholarship funds are limited, and made possible by the generosity of many individuals, families and small fundraising events. The Alec G. Cunningham Board of Directors will determine applicant eligibility for scholarships and amounts awarded based on the information recorded below and available scholarship funds. mAXImUm SCHoLArSHIp AmoUnt IS $500 BASED on AVALIBLE fUnDS AnD nEED.

Camper Name: _______________________________________________________ Age: ______________ Grade: __________________

Address: _____________________________________________________________ City: _______________________________________

State: _________________________ Zip Code: ________________________________ County:_________________________________

1. Indicate your family circumstances by accurately completing the information below.

Gross family income from all sources: _______ < $30,000, ______ $31 - 50,000, ______$51 - 70,000

______$71 - 90,000, ______$91 – 110,000, _____>$ 110,000

Number of people dependent upon above income: _____ 1, _____2, _____3, _____4, _____5, _____6, _____> 6

2. What other potential funding sources have you investigated?

________church/religious organization (s), ________ community/humanitarian organization (s),

________disability funding agencies, _________ personal fundraising, __________ extended family/friends

________ other (explain) __________________________________________________________________________________

Contact Indian Trails Camp for fundraising ideas, or ideas can be found at: www.campalec.wordpress.com

3. record below any extraordinary circumstances that we should take into consideration.

________ live independently, _______ change in level determination, _______ unusual medical expenses,

_______unemployed, ________ sudden change in circumstances, other ________________________________________________

_______________________________________________________________________________________________________________

4. Complete the calculation below to determine the requested scholarship amount.

totAL DUE (from financial form): $_______________ - AmoUnt I CAn pAy: $___________________

- AmoUnt from otHEr SoUrCES $______________ = rEQUEStED SCHoLArSHIp: $________________

5. return the Scholarship Application form with your application.

I attest that the information recorded above is accurate to the best of my knowledge.

Signed:______________________________________________________________________ Date:____________________________


LEVEL DEtErmInAtIon

level determinationLevel 1 (1:3)Campers are provided one direct care counselor per three level 1 campers. Level 1 is for campers who are able to perform most of their ADL’s (Activities of Daily Living) independently. Campers in this level take between 0-4 medications per day and do not have any current ongoing medical concerns. Camper is independent with eating, or requires some verbal prompts and/or with minimal physical assistance (e.g. cutting up food). Camper is independent with hygiene needs, or may require some verbal prompts to ensure completion or thoroughness. Camper is Independent with toileting, or requires minimal verbal prompts. Camper is independent with practicing coping skills and staying focused on task at hand, or requires minimal verbal prompts or redirection.

Level 2 (1:2)Camper at this level are served with one direct care counselor per two campers. Level 2 Campers require some physical assistance but are independent in other areas of care. Camper in Level 2 may not exceed 8 medications to be taken daily, and may have minimal medical concerns. Camper may require minimal physical assistance with accessing food at meals, and/or requires specialized diet/nutrition (e.g. puree food). Camper may require minimal physical assistance with hygiene needs to ensure completion or thoroughness. Camper may require minimal physical assistance (e.g. wiping) with toileting. Camper may require verbal prompts or redirection with practicing coping skills and staying focused on task at hand. Camper may be dependent on a mobility device (e.g. walker, cane, etc) but is able to use this primarily independently.

Level 3 (1:1)Level 3 is reserved for campers who need one-to-one assistance the majority of the time due to medical or behavioral situations. Medications may exceed 8 per day. Campers who require medical treatments such as feeding tubes and severe seizure monitoring are automatically Level 3. Camper may require full assistance with accessing food at meals. Camper may require full assistance with most or all hygiene needs. Camper may require full assistance with toileting including transferring, diapering, and wiping. Camper may require verbal prompts and redirection with practicing coping skills and staying focused on task at hand most to all of the time. Camper may be dependent on a mobility device (e.g. manual/electric wheelchair, scooter, etc) at all times, and may be independent with using it or needs assistance. Camper may be a flight-risk.

If you are unsure of which level maybe most appropriate please contact Indian Trails Camp at 616-677-5251.


InSUrAnCE form

Camper Name: ___________________________________________________________

* IMPORTANT: Indian Trails Camp, Inc. does not carry medical/accident insurance for campers. It is the responsibility of the camper/guardian to obtain adequate insurance coverage for any medical needs, including accidents.

I understand the above: __________________________________________________________________________________________ Signature parent/guardian or adult camper

Is the camper covered by medical insurance? yes ___ no ___

If yes, please list the camper’s health insurance carrier (examples: Blue Cross, medicare, ppom, etc)

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

policy number: __________________________________________________________________________________________________

Contract number: _______________________________________________________________________________________________

Card Holders name: _____________________________________________________________________________________________

PleAse attach a current copy of the card to this form.

Additional information:____________________________________________________________________________________________

_________________________________________________________________________________________________________________

Camp ALEC Session


CAmpEr pHySICAL form

This form MUsT be completed by a licensed physician on or after 2/1/2016. This form MUsT be completed in its entirety. We CANNOT accept applications for campers with incomplete medical information.

Camper name _______________________________________________________ D.o.B___/___/___ Sex _________

1. Applicant must be diagnosed with a physical disability, developmental disability, mental illness, Downs Syndrome or Autism. 2. Applicant must be capable of social interaction and participation in camp activities. 3. Applicant must be able to communicate needs through at least a yes or no response (e.g. eye blinks, headshake, or use of

communication board, etc).

primary Diagnosis/disability:______________________________________________________________________________________

Secondary Diagnosis:_____________________________________________________________________________________________

Other information for health care staff, including treatments to be continued at camp, activity restrictions, medically prescribed meal plan or dietary restriction while at camp _______________________________________________________________________________ _________________________________________________________________________________________________________________

I have treated this applicant for:____ years___months and am familiar with the camper’s disabilities. In my opinion, the applicant is physically and emotionally able to participate in an adaptive camp program. the information provided on this form represents my authorization for distribution of medications as well as treatment/care.

_______________________________________ __________________ _______________________________________________________ Physician’s Signature Date Physician’s Office Name & Phone #

medical History__Asthma/Respiratory problems __Apnea__Diabetes type: ____________ __Kidney Disorder__Heart Defect __Other Does the camper frequently suffer from any of the following (check all applicable)?__Headaches __Sore Throat __Ear Infections Immunizations (check all that has been issued):__Diphtheria __Measles __Small Pox__Pertusis __Polio __Rubella

Date of last Tetanus ___/___/___ (must be within 10 years)Date of last TB test ___/___/___ (must be within last 3 years-attach copy of TB card) Result: ___Positive ___Negative If positive, date of X-ray ___/___/___

Does camper have known communicable diseases?__Measles __Hepatitis: A B C (circle one) __HIV positive__Chicken Pox __Other: __________________

Allergies and Reaction: ________________________________________________________________________________________

Seizures –indicate type, length and frequency: ____________________________________________________________________

______________________________________________________________________________________________________________

Current Health: Age___ Weight _____ BP______ HR_____ RR _____ Temperature_____ Pulse Ox ______

Overall health condition:


mEDICAtIon rECorD

please list All medications. the back of this sheet may be used if needed.

NOTe: Camp medications are distributed at 9AM, 12N, 2-4PM, 5PM, and 9PM. Any deviations must be indicated by a physician. Only medications and dosages listed on this form will be approved on camp registration day. Any medications not listed on this form will not be administrated at camp without prior written approval of the physician. This includes ALL over the counter non prescriptions and prescriptions medications. Medications must be brought in their original bottles. If you choose to bring them set up in a med container, pill bottles must still be brought to verify prescription. **Please be sure to obtain written approval for any deviations of prescriptions written on bottle prior to camp registration.

name of medication Dosage prescription, as listed on bottle** time(s) given

Depakote 250mg 3 tabs by mouth twice daily 9am and 9pm


SUmmEr CAmp CHECkLISt

Drop off tImES for CAmp ALEC IS 3:00pm - 5:00pm

pICk Up tImES for CAmp ALEC IS 10:00 Am -12:00 pm. you will have a chance to meet with your child’s literacy Counselor at this time.

This session has only 20 slots and will fill up fast. Please send your application, financial form, level of determination, IEp and copy of insurance card with your deposit as soon as possible to reserve your spot. If an

agency or insurance company pays in full for your session your initial deposit will be returned to you. If yoUr CAmpEr HAS BEEn ACCEptED to CAmp ALEC yoUr DEpoSIt WILL not BE rEfUnDED.

NOTE: Please send all forms as soon as they are completed. Final acceptance/confirmation notices will be sent once all completed paperwork is received. We would advise you to mail us the completed application, financial

form, level of determination, IEp and copy of insurance card even if you do not have the physical form completed so that your spot is reserved. then mail in the physical form upon completion but no later than 3 weeks prior to

camp session.

AppLICAtIonS ArE DUE mAy 28, 2016 At WHICH tImE WE WILL opEn Up Any AVAILABLE SpotS to tHoSE WAItLIStED.

We will continue to accept applications after this date if spots are still available.

mail applications to:

Camp ALECC/o gina Cunningham44125 Cottisford Street

northville, mI 48167

or fax to:1(248) 869-6073

for additional information please contact us at [email protected].

DAtE SEnt form nEED By

_________________ 13-page ApplicationASAp *Note Applications are due by May 28, 2016. After this date applications will still be considered if slots are still available.

_________________ financial form ASAp *Note: Send with application_________________ Level of Determination ASAp *Note: Send with application_________________ most recent IEp ASAp *Note: Send with application_________________ Insurance Card ASAp *Note: Send with application_________________ physical form 3 weeks prior to camp session

2016 camp alec application

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