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Camp Patterson 2015 Registration/Application and Medical Information Form Revised 3/18/15 Return application to: Everett Parks and Recreation, 802 E. Mukilteo Blvd, Everett WA 98203 This form must be signed by a parent or guardian. The information will be used to assist the staff in meeting your child’s needs. . Camper’s Name: Birth Date: Camper First Last Male Female Special Ed Regular Ed New Camper Returning Camper Parent/Guardian: E Mail Address: Camper Address: City: State: Zip Code: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Cell phone: ( ) EMERGENCY CONTACT (if not able to reach parent/guardian) Name Relationship Home Phone: ( ) Work Phone: ( ) Name Relationship Home Phone: ( ) Work Phone: ( ) Please list anyone other than those named above who may pick up your child from camp. (Only those named on this form will be allowed to leave with your child unless you personally speak to a staff member and leave a written permission slip.) Name Relationship Phone Name Relationship Phone Eligibility The camper: Yes No 1. Is between 5 and 21 years of age during camp? (Must be at least 5 years old by July 1, 2015) 1. 2. Is able to perform all personal care needs independently? Personal care needs include but are not limited to dressing, eating and toileting. 2. If NO, then I understand that I may need to provide a personal care attendant for my child. Name of Personal Care Attendant: 3. Exhibits behavior that poses a threat to themselves or others? 3. 4. Is able to stay with the group to which they are assigned? 4. If NO, than I understand that the camper MAY not be eligible to attend Camp Patterson without an attendant. 5 How is camper getting camp? Private car ParaTransit/DART Regular Everett Transit Bus Route T-Shirt size: Youth: xs Small Med. Large Adult: Small Med. Large XL XXL Registration Sessions Attending: Fee (10am- 3pm) Extended Hours: Fee Sessions Attending: Fee 10-3 Extended Hours: Fee Week 1 June29-Jul 2 $90.00 AM: 7:30-10am $39 Week 4 Jul 20-24 $119.00 AM: 7:30-10am $55 Week 2 Jul 6-10 $119.00 AM: 7:30-10am $55 Week 5 July 27-July 31 $119.00 AM: 7:30-10am $55 Week 3 Jul 13-17 $119.00 AM: 7:30-10am $55 Week 6 Aug 3-7 $119.00 AM: 7:30-10am $55 Adults Only Week 7 Aug 10-14 $119.00 No extended hours Age 18+ Total Camp Fees $ If registered for extended care, please note the intended drop off time: Total Extended Hours $ (Not before 7:30 a.m.) Drop off time: Total Due $ Scholarships are available for those who qualify. Call [PHONE REDACTED] X 2 Payment Enclosed $ Registration Fees due upon submittal of this form. Make checks payable to: City of Everett To make a credit card payment, please contact the Recreation Office at [PHONE REDACTED] ext 2 – Visa and Mastercard credit cards are accepted Payment Owed $ If payment is NOT enclosed, then you MUST attach a written statement of responsibility from the funding source and complete the following information in full and SCAN to [EMAIL REDACTED] or FAX [PHONE REDACTED] Who is responsible for payment? DDD/DSHS Other (please specify) Case Manager Name: Contact Phone: Case Manager Email: ---PAGE BREAK--- Medication Participants must be able to take their own medication while at Camp. If medication is required during Camp hours, a Medication Information and Waiver form must be signed and returned. Send me a copy of your medication policy and Medication Information and Waiver Form. Yes No Please list all meds camper is currently taking: Medicine type: Dosage and times taken: Does medicine create side effect? Yes: No: If Yes, please explain: Medicine type: Dosage and times taken: Does medicine create side effect? Yes: No: If Yes, please explain: Medicine type: Dosage and times taken: Does medicine create side effect? Yes: No: If Yes, please explain: ALLERGIES (Pollen, Insect, Drug, Food, etc.) List: Reaction: Treatment: General Questions Does/has the camper: Yes No Yes No 1. Had any recent injury, illness or infectious disease? 6. Ever had an eating disorder? 2. Ever had frequent ear infections? 7. Ever had problems with joints? 3. Ever passed out during or after exercise? 8. Have any skin problems? 4. Ever been dizzy during or after exercise? 9. Have diabetes? 5. Ever had seizures? 10. Have asthma? Please explain any “yes” answers, noting number of the questions: Special Interests Can camper swim in a lake? Yes No List any restrictions: What are child’s favorite activities? Additional comments and important information (helpful suggestions about interests, difficulties, etc.). Add hints and behavior patterns that will assist the staff in making this experience successful. Use separate sheet if necessary. Is your child appropriate for this program? Yes No Please tell us anything that might affect your child’s ability to participate in camp activities. Lifeguards supervise all water activities. Lifejackets are required on docks and in boats. The following is a partial list of items to consider: Can your child: play active games, swim in lake, (with or with/out lifejacket – circle one), get in and out of canoes, walk up and down hills, get in and out of vehicles – We would appreciate any information about your child and your child’s behavior that will help us give your child a great camp experience. What do you expect your child to gain from this camp experience? ---PAGE BREAK--- Check all items that apply Developmental Delay Visually Impaired 1-2 yrs 3-4 yrs More than 4 yrs Blind Partial vision, which eye: Rt Lft Wears glasses Emotional Disability Communication Accommodations Severely emotionally disturbed Understands English - if not, what Other Can speak in English to make needs known - Utilizes what communication aids: Physical Disability Accommodations: Deaf Partial hearing - which ear: Will bring wheelchair Manual Electric Wears hearing aid Signs - Ability level: Will bring walker Will bring crutches Reads lips - Ability level: Uses braces Other Describe how we can best accommodate your child: Emotional Challenges YES NO Eating - Does camper…. What triggers an outburst? Self feed with spoon or fork? Drink from glass? What is the best method to calm down your child? Self finger-feed? Have dietary restrictions? Specify: Does child have behavior problems at home? At school? Tend to overeat? YES NO Toileting - Does/is camper Totally independent? Use the toilet? How does he/she communicate need to use toilet? Need assistance? – How much?(Be specific) Use diapers? Doctor’s Name Doctor’s Address City PARENT/GUARDIAN/PARTICIPANT PERMISSION: In consideration of the City of Everett granting me or my child (“child” includes any person I am legally responsible for) the opportunity of attending or participating in the Camp Patterson Day Camp Program for the purpose of leisure enjoyment; and recognizing the fact that no benefits are derived by the City of Everett by allowing me my child to attend or participate; I, the undersigned, hereby release and hold harmless the City of Everett, its officers, employees, volunteers and agents, and the State of Washington and all of its agencies, agents, contractors, servants and employees from any and all liability claims, damages, costs, and expenses for personal injury, including death , or property damage, or both, related to my or my child's participation in the program. I agree to assume all risks associated with the program. In case of any emergency, and you are unable to contact me/us and/or you believe it is necessary to obtain the services of a doctor and/or hospital without first contacting me/us, I hereby authorize you and my doctor or hospital to immediately render all services and treatment deemed necessary at my/our expense. I believe that I or this child is not at risk of harming him/herself or others while in attendance in this day camp program. I certify that the above information is true, correct, and complete. I understand that I or my child may become ineligible for any misrepresentations, falsifications or omissions in the above statements. The undersigned agrees to release the City of Everett, its officers, agents, volunteers and employees, from any and all claims, suits, actions, damages, or compensation in any way related to the use and reproduction of photograph(s) taken of me, or my child, which are used in City sponsored publications. Signature of Parent/Guardian or Participant (if legally competent to sign) Date