ontario aphasia retreat day 2017 application #: application form · 2017. 6. 28. · ontario...
TRANSCRIPT
Ontario Aphasia Retreat Day 2017 Application #:____
Application Form
Thank you for your interest in Aphasia Retreat Day 2017! Date: Saturday, September 23, 2017 Time: 9:00 am – 5:30 pm Location: Woodeden Easter Seals Camp 2311 Oxford St W, London, ON N6K 4P1 Application: Every participant must fill out an application form. Submit by Monday July 31, 2017 to Alexis Dickson. Contact information at the end of this form.
PARTICIPANT INFORMATION
I am a person with Aphasia and I am accompanied by________________________
I am a person with Aphasia and I am attending alone
I am a friend/family member accompanying_______________________________
Have you attended Aphasia Camp before?
2008 2009 2010 2011 2012 2013 2014 2015(Retreat Day) 2015 (Full Camp) 2016 (Full Camp)
CONTACT INFORMATION
Last Name:
First Name:
Address:
City: Postal Code:
Telephone #: Email Address:
Date of Birth: Gender: female
woman
Emergency Contact Name:
Contact Person’s Phone #:
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HEALTH INFORMATION Please check all that apply.
stroke Seizures brain injury headaches
swallowing digestion diabetes
type 1 type 2
pregnant
vision
blood pressure
high low
angina
heart attack
heart disease wear glasses
chronic pain / arthritis
other joint concerns back pain hearing
wear hearing aid
asthma breathing problems incontinence bowel problems
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Other:
What else do we need to know about your medical condition?
List your medications (or attach list).
I will need help managing my medications.
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Allergies: yes no
trigger mild moderate severe
wheat
eggs
fish
dairy
peanuts
other nuts
shellfish
soy
Outside : trees, grass, etc.
Insects: bees, wasps etc..
other:
Do you use an EpiPen®? yes no
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Special Diet: yes no
diabetic vegetarian vegan
gluten free low salt dairy free
pureed soft chopped pureed
thickened liquids ( nectar honey pudding)
no pork products
other: _________________________________________________
ACTIVITIES OF DAILY LIVING
NOTE: There will be attendants at the retreat day available for assistance.
Will you require attendant services during the day? yes no
Are you able to climb stairs safely without assistance? yes no
When going to the toilet, I use a:
raised toilet seat
commode
grab bars
left right catheter
none of these other: ______________________________
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I need help with:
help
activity none some a lot
eating
toileting
showering or bathing
dressing
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MOBILITY
Do you use an assistive device to move around? yes no
If yes, what device do you use?
How much help do you need?
help
device none some a lot
cane
walker
wheelchair
COMMUNICATION
I have difficulty with:
type none some a lot
understanding
talking
reading
writing
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What helps you to communicate? Please circle.
writing
drawing
communication book
choices
iPad or device
camera
family or friend
extra time
gesture
pointing
pictures
maps
speak slowly boating key words
quiet
Other:
PAYMENT
Please enclose cheque or credit card information with this application.
All financial information is confidential and destroyed once payment is processed.
Application will only be processed when payment is received.
Cost: $45.00
Cheque
Make payable to: March of Dimes Canada
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Credit Card:
Visa MasterCard American Express
IMPORTANT: We will call you for your credit card information upon your
acceptance to camp 2017.
Consent
The attendant services staff may help me with my medications.
yes no
If I have a medical emergency, my emergency contact will be phoned.
If they cannot be reached, 911 may be called.
yes no
Photographs, videos, and/or stories of me may be used by: yes no
March of Dimes Canada yes no
Signature of applicant:
Date:
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It is important that we have all information.
The Aphasia Retreat Day Planning Committee will review all application so we can meet your medical needs to the best of our ability.
At this time we are unable to provide support for some medical conditions.
Send your application and payment to:
Alexis Dickson March of Dimes Canada 10 Overlea Blvd Toronto, Ontario M4H 1A4 Email : [email protected] Phone : 1 800 263 3463 x 7756
Please note that submitting an application does NOT guarantee acceptance.
Applicants will be notified by mail by late August of their acceptance status.
We will not charge you if you are not accepted.
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Registration is at 9:00 am. Pick up at 5:30 pm.
People with aphasia, please help us with our planning by indicating your first and second choice for each time slot. Please note that your first choice is not
guaranteed. However, we will do our best to accommodate everyone. Friends and family we have exciting plans for you too- please see below the adapted
activities for your schedule!
This is a tenative schedule subject to change.
10:45-11:45 am
1:15- 2:15 pm
3:00-4:00 pm
Caregivers/Friends/Family
10:45-11:45am: Yoga 1:15-2:15pm: Painting art activity
3:00-4:00pm: Networking session on the importance of leisure/stress management and self-care
We look forward to a day away with you!
adapted floor hockey
adapted archery
adapted yoga adapted archery
adapted archery nature candles craft