CAMP AVANTI . . . ICAGHOWAN YMCA Camp Icaghowan, 899A 115th St, Amery, WI 54001 DAY CAMPER APPLICATION____ New Avanti Camper ____ Returning CamperCamp Dates: Sunday, July 3 to Friday, July 8, 2011Application Deadline: March 18, 2011Intake interviews will be July 3rd, and exit interviews will be July 8th.***Please complete this entire application. Respond to the questions carefully as this information willhelp us determine what support is needed for success at Camp Avanti. If they have not had one, asensory integrative evaluation by a qualified occupational therapist may be requested prior toacceptance. We are not able to accept all applicants. ***Child’s name DOB Sex F MAddress City State Zip Home phoneParent or Guardian name Relation to camper Work phone EmailFamily Doctor Address PhoneMEDICAL:Medical /Psychological Diagnoses ________________________________________________Current medications and what they are treating _______________________________________________________________________________________________________Does the camper require a special diet? If yes, describe in detail. _______________________Allergies (especially insect bites or poison oak)Significant physical injuries in the past (describe and give dates)Does your child have vision or hearing problems? ______ ___________Activity or swimming limitations?Any communication problems?
CAMPHas the camper ever slept away from home? (Day campers often have the opportunity to sleep overon Thursday night of camp) _________________Person who referred you to camp and why _____________What do you hope will result from this camp experience?Does the camper require assistance to stay with a group?When might the camper require assistance to stay safe?Please describe your child’s leisure activities _____Does the camper like group activities?What camp activities do you think he/she will enjoy? _____Does the camper tend to be afraid? If so, of what?What type of help does your child need to manage using the bathroom or changing into their swimsuit? ___________________________________________________________________What type of help does your child need to participate successfully in a group of kids? ___ ___ _____________________________________________________________________ _THERAPYHas this child received previous occupational therapy? Evaluation and/or treatment? Please givefacility, dates, and therapist __________________________________________________ ______________________________________________________________________Please check the OT/ sensory processing problem areas that apply to your child:___ sensory defensive ___ arousal/alert control ___ self awareness___ motor planning ___ oral motor ___ fine motor ___ gross motor___ social awareness ___ emotional self control ___ transitionsEDUCATIONSchool Teacher GradeDoes your child receive special education services? ___ Yes ___ NoWhat services? ___ reading ___ math ___ behavior ___ speech/lang ___OT ___ PT(Check all that apply)What support does your child need to function in a group in the classroom, phys Ed, and/orplayground? ___ none /cues from main teacher ___ Para/aide part time___ Para/aide 1 to 1
STRESS MANAGEMENT/ COPINGWhen there are times or situations in which your child has more difficulty... how does he/sherespond? (Circle) withdrawing, fleeing or becoming verbally or physically aggressive.What are the most successful strategies for helping your child cope with stress—before/ during/ andafter incidents?____________________________________________________________________________________________________________________________________________Has your child become verbally or physically aggressive in the past 6 months? (Circle which) yelling,swearing, name calling, scratching, pushing, hitting, kicking, or other: how often? _______________,describe: _________________________________________What adult approach appears to help them switch to more appropriate behavior?____________________________________________________________________Please attach additional information concerning your child if we failed toask something you feel is important!!Camp Dates: Sunday, July 3 to Friday, July 8, 2011Application Deadline: March 18th, 2011Fee: $ 600 The $100 deposit should be mailed with the application, and will be held until notification of acceptance in March, when the balance is dueMake checks payable to: Avanti OT Projects **please write camper’s name and “Avanti” in the memo”Mail to: Avanti OT Projects, c/o Kris Worrell, 2495 Maplewood Drive, Suite 313, Maplewood, MN 55109*See attached for information on financial aid. We have limited scholarships available. Pleaseindicate your need and what you plan to do to raise funds.Please use email for communication as much as possible – most staff are volunteers.Co Directors this year are Kris Worrell and Eileen Richter.To contact: CampAvanti@gmail.com, or call 651-770-8884 Signature Relationship to child Date**** I hereby give permission for Camp Avanti administrative staff to contact a professional at mychild’s school who is familiar with him/her. I understand that the information obtained will be used forthe sole purpose of determining the level and type of support needed for a successful campexperience for my child._____________________________ _________________ __________Person to contact phone number job/ role_____________________________ _________________ __________Signature relationship date
***For Returnees only*** We will be applying for grants and they often require us to report feedbackfrom parents. Please check the areas where you saw progress after the last session of 2009 camp.Then give brief descriptions. Thank you!___ Independence ___ initiation ___ motor skills ___ calm focus/ attention ___ self care ___social ___ self controlComments _______________________________________________________________________________________________________________________________________________