Easter Seals Iowa

Supported Day Camp 2015 Checklist

As you complete the application, please check off the items from this list:

___ 2015 Application

___ Health History Form + immunization records

___ Easter Seals Physical Form (new requirement for supported day camp)

___ All Release Forms (Notice of Privacy Practices, Waiver of Liability, Photo Consent Form)

___ Physical signatures on the required pages (we do not accept electronic signatures)

___ Financial Information Form

___ Supported Day Camp Registration Form

___ Current Individual Care Plan/Consumer Comprehensive Service Plan and Release of Information (waiver clients only - please contact your case manager)

___ Notice of Decision or $50 non-refundable deposit

We require all items on this list to be submitted in order to begin the registration process. Please send them to our Program and Support Specialist, Kate Simpson, by the following methods:

Email: ksimpson@eastersealsia.org

Fax: 515-289-1281

Mail or Drop Off: Easter Seals Attn: Kate 401 NE 66th Ave Des Moines, Ia 50313

Once we have registered you for camp, you will receive a letter via mail confirming the week(s) you are registered for. Please contact Kate at 515-309-2375 or ksimpson@eastersealsia.org if you have any questions.

If you are new to Camp Sunnyside Supported Day Camp… Once you have turned in all of the items on the checklist, our outreach coordinator, Renee Bell, will contact you to set up an intake meeting. After you have done the intake, you will have the opportunity to be registered for camp. A new camper cannot attend camp until this process is complete. Once you have been registered, you will receive a confirmation letter in the mail.

IMPORTANT!

If you are PRIVATELY PAYING:

- A non-refundable $50 deposit is required to register a camper. The camper cannot be registered until we receive this and we do not reserve or hold spots. The $50 will be applied to the first camp session. Please send the deposit with the application to our program and support specialist, Kate Simpson, at:

Easter Seals Iowa Attn: Kate Simpson 401 NE 66th Ave Des Moines, IA 50313

- Full payment is due three weeks before the client attends his/her camp session. Failure to pay in advance may result in a loss of registration for that session. If the remaining balance is sent separately from the deposit and application, please send it to our Accounting Department at:

Easter Seals Iowa Attn: Accounting 401 NE 66th Ave Des Moines, IA 50313

- The entire amount is required to be paid even if the camper will not attend the entire camp.

- If the camper can no longer attend the registered camp, you must contact Kate Simpson at 515-309-2375 to cancel the session. You must cancel prior to the camp session. If you fail to cancel the session, you will be personally billed for the full amount of your camp session, regardless of original payment source.

How to Apply for a Campship:

Easter Seals Iowa receives funding from a variety of sources, including private donations, government agencies, and fee-for-service. To make our services accessible to as many people as possible, Easter Seals Iowa also relies on contributions. Public contributions help cover the difference between actual program costs and for those who are unable to pay for all or part of the service. Each camper is supported by donors who participate in the Annual Fund Campaign. The Annual Fund raises donated funds for these financial gaps. Campships are scholarships that are gifts from the Pony Express Riders of Iowa, the Annual Campaign, foundations, organizations, and individuals.

- To apply, please fill out the Campship request section on the 2015 Financial Information page.

- If applying for a Campship, we still require the non-refundable $50 deposit. Deposits are not covered under a Campship. Please send the deposit with your application.

- If awarded a Campship, you will receive a statement reflecting that it has been applied to your balance due.

- Clients are eligible to receive one Campship per season, not to exceed $550. Residents of group homes, nursing homes, and other facilities are eligible for a maximum Campship of $250.

- There are limited Campships and we reward them on a first come, first serve basis. If you are interested in receiving one, we strongly encourage you to turn in all the required documents for camp as soon as possible.

IMPORTANT!

If you are using WAIVER FUNDING:

- Contact your case manager before sending in the application. Please discuss with them how many camps you are interested in, what type(s), and what dates the camps occur on.

- Please send the NOD with the application to our program and support specialist, Kate Simpson, at ksimpson@eastersealsia.org or:

Easter Seals Iowa Attn: Kate Simpson 401 NE 66th Ave Des Moines, IA 50313

- Please also have the case manager send the client’s Individual Care Plan/Consumer Comprehensive Service Plan (ICP/CCSP) with the application and the NOD. This document is also required for registration.

- A camper cannot be registered without a correct NOD and we cannot register outside of what the NOD authorizes. We also do not reserve or hold spots.

- The entire unit amount per camp is required to be authorized on the NOD, even if the camper will not attend the entire camp.

- Below are our waiver rates:

Supported Day Camp: T2037 Respite Non CMH: T2036 $1.11/unit $3.16/unit 180 units a week 184 units per weekend (220 units per week for extended hours) or

Respite CMH: T2036 Resident Camp: T2036 $3.34/unit $1.24/unit 184 units per weekend 484 units per week

PLEASE NOTE:

- The CMH waiver (Children’s Mental Health Waiver) can only be used on our weekend respite

camps.

- All other waivers (such as the Intellectual Disabilities Waiver, the Ill and Handicapped Waiver,

and the Brain Injury Waiver) are eligible for both weekend respite camps and our summer

resident and supported day camps.

Easter Seals Iowa Camp Sunnyside

-Financial Form- *this form is required for summer camp registration*

Client Name: Birthdate:

Party Responsible for Payment:

Billing Address:

City, State & Zip: Phone:

Email Address for Billing:

Case Manager Name: Agency:

Case Manager Address:

City, State & Zip: Phone:

Case Manager Email:

I prefer electronic billing statements

PRIVATE PAY

Method of Payment:

Check (make payable to Easter Seals Iowa)

Amount Enclosed: $_________________

Credit Card □ Visa □ MasterCard □ Discover

Amount Authorized: $_______________

Card Number: ____________________________________

Expiration Date: ________________

Name on Card: ___________________________________

Signature: _______________________________________

$50 deposit required

WAIVER FUNDING

Medicaid ID: ________________________________

Notice of Decision and CCSP required (please contact your case manager)

If you are paying with waiver and a private payment, please attach notes with details.

REQUESTING CAMPSHIP

(not guaranteed – private pay, resident camp only)

Amount Requested: $__________________________

Annual Income: $__________________________

$50 deposit required

Please note:

The non-refundable $50 deposit must be sent with application if you are privately paying. It will be applied

to the first camp session.

Full payment is due THREE WEEKS before the client attends his/her camp session.

Failure to pay in advance may result in a loss of registration for that session.

Client Name: ________________________________________ Today’s Date: ______________ Medicaid or Social Security Number: _____________________ Date of Birth: ______________ Is the client new to Easter Seals Summer Camp? [ ] Yes [ ] No Guardian Name: __________________________ Guardian Email: ________________________ Guardian Home Number: ___________________ Guardian Cell Number: ___________________

Easter Seals Iowa Camp Sunnyside

- SUPPORTED DAY CAMP - Registration 2015

Check in is weekdays 8-9 am. Check out is weekdays 4-5 pm. Extended hours are available. Camp registration closes the Wednesday before the desired camp.

Supported Day Camp is for ages 6-17 Client Age: ____________

*Please mark all sessions you would like to attend*

D1 June 8-June 12 Camp Explore D2 June 15-June 19 Rock N’ Roll Daze D3 June 22-June 26 Western Week D4 June 29-July 3 Party in the USA D5 July 6-July 10 Jurassic Camp D6 July 13-July 17 Amazing Race D7 July 20-July 24 Splash Off! D8 July 27-July 31 Fun and Fitness

Please list any alternative sessions you can attend in case your first choices are full.

1. _____________________________ 2. ________________________________

Private Pay Cost: $200 per week Waiver Rate: $1.11 per unit, 180 units per week (220 for extended hours)

-Extended Hours- for Supported Day Camp

Name: __________________________ Date: _________________ Normal check-in and check-out times for Day Camp are 8:00 am - 9:00 am and 4:00 pm - 5:00 pm.

Extended hours run from 7:00 a m - 8:00 am and 5:00 pm - 6:00 pm. If you chose to utilize these hours, you must fill out and turn in this form. Private Pay Clients: Extended hours are available for an additional fee of $25 per week. This payment must be paid in full before the session starts. Waiver Clients: Payment for extended hours will need to be reflected in the Notice of Decision provided by your case manager. The units for one week of camp will need to increase from 180 units to 220 units to accommodate extended hours services. Please make prior arrangements with your case manager. We must have an NOD with the additional units before the session starts.

Please check each week that you will be using extended hours and if they will be between 7-8am, between 5-6pm, or both times.

1- June 8-June 12

2- June 15-June 19

3- June 22-June 26

4- June29-July 3

5- July 6-July 10

6- July 13-July 17

7- July 20-July 24

8- July 27-July 31

Between 7-8 AM

Between 5-6 PM

Both AM & PM

LATE FEES The Day Camp Programs will maintain strict adherence to the 6:00 p.m. closure time. If a client is not picked up by the appropriate designee by this time, a late charge will be enforced. For private pay clients: There will be a late charge of $10 due at the time of pick-up if a parent comes for a client between 6:00 pm – 6:10 pm. After 6:10 pm there is an additional charge of $1 per minute. For waiver clients: NOD hours will be utilized for services provided on 15 minute increments.

Day Camp 2015

-Theme Descriptions-

Camp Explore Camp Explore is being offered to all persons in Iowa with visual impairments. Easter Seals Iowa is collaborating with Iowa Braille School to make this a special session designed for persons with visual impairments, but anyone is welcome to join in the fun. This is a youth session. Rock ‘N Roll Daze If you like to rock and roll, this camp is for you! With music blaring all week long on the patio and a live performance by a cover band, this week totally ROCKS! We also encourage our campers’ creativity by making music and instruments of our own. Western Week Yeehaw! It’s back again for another time around the barrel! Enjoy a rodeo, horseback riding, and lots of Country Western Music during this honky-tonk week. We will also turn camp into the Wild West with demonstrations from the Pony Express Riders of Iowa. Costumes and Western wear are encouraged! Party in the USA This eventful week is all about festivities and having fun! Each day we will celebrate a different holiday by having a party. Campers will get to experience Halloween, a winter wonderland, Valentine’s Day, and of course, Independence Day all in one week! Bring your party hats! Jurassic Camp This prehistoric session will be full of dinosaur searching fun! Throughout the week, campers will explore high and low for fossils and animal tracks, in addition to creating some of our own. Join us in scavenger hunts on our very own nature trail and learn about all of the great nature Camp Sunnyside has to offer. Amazing Race Travel around the world without leaving Camp Sunnyside! This adventurous camp will be full of cuisine and activities from around the world. Campers will be able to sample activities and food from China, Mexico, Italy and more during this week of international fun. Splash Off! Be sure to bring your swimsuit to this wet and wild week! We will have pool parties and boat parties on Lake Cheerio, as well as our slip and slide. Don’t forget about our water fights as well! Fun and Fitness This camp week will be full of high energy activities that EVERYONE can enjoy. We will have yoga and water aerobics, as well as daily hikes around Camp Sunnyside. We will also offer exercise classes throughout the week and be offering new activities that will surely appeal to all campers!