Youth Summer Program Registration Form

2. Summer Program Membership Participant's Full Name Age DOB Home Address Parent/Legal Guardian Full Name Child's School and District Parent Address (if different from child) Father Occupation Phone Email Mother Occupation Phone Email

Primary Contact

Name Relationship to child Cell Phone Home Phone

Secondary Contact

Name Relationship to child Cell Phone Home Phone

Medical Issues/Allergies

Transportation (If transportation is needed, please let us know and we can discuss possible options.)

Drop Off By Cell Phone Pick Up By Cell Phone

Releases and Refunds

Please INITIAL each box after reading the corresponding statements. 1. I hereby give permission for me/my child to be photographed by Camp Connections/Ability Connection Staff and understand that such photographs become the property of Camp Connections/Ability Connection, and may be used for future promotions relevant to the program.2. All participants must abide by all rules, regulations and guidelines set forth by the program and may be dismissed from the program at the discretion of the Vice President of Youth Services.3. The risk of sustaining injuries results from the nature of the activity and may occur without fault of the participant, Camp Connections, staff, volunteers, or the facility.4. A refund may be given for medical reasons only with a doctor’s note. Refunds will be issued within 30 days following an approved refund request and issued in the form of a check. Approved refunds will be charged a $10 administration fee.5. If applicable, I am aware children will only be released into the custody of the parent/guardian and those listed above unless I notify management.

I have provided the correct information; I have read all of the information on this page; I hold Ability Connection harmless of any associated risks.

Parent/Guardian Signature Date

3. Abilities, Skills & Goals

In order to best serve our members, we invite parents to share knowledge of their child’s abilities, skills, and goals as early as possible. This information is crucial to our program for the following reasons:

Providing a foundation for effective planning
Providing a base to foster mentoring relationships with members
Assisting staff with realistic individual goal setting for members
Effective planning to increase the likelihood of achieving their goals
Promoting achievement of academic and social skills

What are his/her specific disabilities? Any sensory issues? How have the disabilities impacted their life? (learning, self-care) What are his/her primary skills? (functional, academic, social) What 3 goals would you like him/her to focus on? (Based on IEP) Completing this section allows Camp Connections to best serve my child. If these details need to be further discussed I will email the VP of Youth Services at YouthServices@abilityconnection.org.

4. Assistive Technology & Devices

Assistive Technology (AT)

Any member who requires AT to communicate or complete tasks must have their device operable and charged for each day. Camp Connections does not provide any AT or other devices for members. Staff persons are not required to operate AT for members but are willing to learn and assist members. In order to do so, Camp Connections requires your consent.

I understand that Camp Connections Staff persons are not trained on AT and I will hold Ability Connection, their staff person, or volunteer harmless for any technological failure, damage, mishandling, theft, or loss.

Cell Phones, iPads, Tablets, Other Devices

Members are allowed to have cell phones. We discourage non-emergency cell phone use. We also discourage bringing gaming, music and non-AT devices to Summer Program, however, Camp Connections does not confiscate members’ devices for any reason. Members are responsible for their own devices and personal belongings, and their devices should remain on their person.

I understand that Camp Connections Staff persons are not responsible for my child’s device(s) and will hold Ability Connection, their staff person, or volunteer, harmless of any technological failure, damage, mishandling, theft, or loss of their device.

5. Safety & Nutrition Agreement

Camp Connections practices a two-deep policy where there are always at least two staff persons present wherever a member is present at all times. Camp Connections does not provide medical attention or treatment to members. If medical attention is needed for a member at any time beyond First Aid treatment, members must have doctor and emergency contacts, medical facility, prescription medication, and food allergy information included in their files. There will be a staff nurse available for First Aid, medication administration, and food allergy purposes only. There will also be at least one staff person trained in CPR in each classroom. CPR can only be performed by the certified staff person while another staff person calls emergency. All Camp Connections staff persons have been trained on policies regarding negligence and protected health information.

Does your child have any food allergies? YesNo

If yes, list food allergens

I hold Ability Connection harmless for responsibilities and risks for my child should any safety or nutritional issue or injury arise.

Medications

List Medications, Vitamins and Inhalants What is it for? Dose? How often? Assistance?

Medication Consent

If you marked “Y” for assistance, be sure to MAKE AN APPOINTMENT with the Vice President of Youth Services to discuss and demonstrate proper medication administration. These details will be entered into our system and maintained in the daily log.

I hold Ability Connection harmless for all responsibilities and risks should any medical, physical, physiological, psychological, emotional, or behavioral issues arise with medication administration.

6. Hygiene & Toileting Consent

Camp Connections and Ability Connection ensure the utmost care when assisting members requiring mobility and toileting assistance. We understand that this support may be related to cognitive development, physical development, or both. Camp Connections is staffed with trained and willing aides to accompany, assist, and “habit train” individuals who may require this support.

Support System

If there is a support system already in place for your child, please share those details below and during the face-to-face (in-person or virtual) follow-up meeting following your packet submission. Camp Connections staff will reinforce what you already have in place to maintain consistency in the habit training.

If there is no consistent habit training in place, Camp Connection is willing to assist and will provide you with some suggestions on the best practices currently in use.

Does your child require any hygiene or toileting assistance? YesNo

If yes, please explain

Is there a support method in place for toileting? YesNo

If yes, please explain:

If you marked “Y” for hygiene and toileting assistance, be sure to MAKE AN APPOINTMENT with the Vice President of Youth Services to discuss and demonstrate proper hygiene and toileting assistance. Camp Connections staff persons designated for hygiene and toileting require in-service training by the Ability Connection staff nurse or the Ability Connection Training Center Director. These details will be entered into our system and maintained in the daily log.

I hold Ability Connection harmless for all responsibilities and risks should any medical, physical, physiological, psychological, emotional, or behavioral issues arise with hygiene and toileting assistance.

7. Emergency Form

Primary Emergency Contact

Name Phone Relationship

Secondary Emergency Contact

Name Phone Relationship

Primary Care Doctor

Name Phone Relationship

Additional Emergency Contacts

Name Phone Relationship Name Phone Relationship

Camp Connections uses best practices in all emergency situations. Should any emergency arise specific to your child, Camp Connections staff is trained to provide basic first aid.

There will be a nurse present on-site or by phone consultation. There will also be a security guard posted on-site during operating hours.

Camp Connections adheres to state codes and standards for emergencies requiring evacuation or sheltering in-place.

If you have any questions or concerns regarding any emergency issues or standards, please type your statement or question below. We will be sure to address this concern by email, by phone, or during the in-person interview.

I hold Ability Connection harmless for all responsibilities and risks should any medical, physical, physiological, psychological, emotional, or behavioral issues arise in the event of any emergency.

I have provided the correct information; I have read all of the information in this packet; I hold Ability Connection harmless of any associated risks.

Parent/Guardian Signature Date

Youth Summer Program Registration Form

Primary Contact

Secondary Contact

Medical Issues/Allergies

Transportation (If transportation is needed, please let us know and we can discuss possible options.)

Releases and Refunds

Assistive Technology (AT)

Cell Phones, iPads, Tablets, Other Devices

Medications

Medication Consent

Support System

Primary Emergency Contact

Secondary Emergency Contact

Primary Care Doctor

Additional Emergency Contacts

Self Pay

Payment options

Tuition Assistance

Our Mission