CAMP AVANTI . . . ICAGHOWAN YMCA Camp Icaghowan, 899A 115th St, Amery, WI 54001 OVERNIGHT CAMPER APPLICATION____ New Avanti Camper ____ Previous Day Camper ____ Returning Overnight CamperCamp Dates: Sunday, July 3rd to Saturday, July 9th, 2011Application Deadline: March 18, 2011***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 without parents? (This is essential, so if not describe yourplan between now and 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 complete self cares such as changing clothes, grooming,showering, and keeping personal items organized? Please describe: __________________________________________________________________________________________________________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? (Check one)___ 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, 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 Saturday, July 9, 2011Application Deadline: March 18th, 2011Fee: $1000 The $100 deposit should be mailed with the application, and will be held until notification of acceptance in March, when the balance is due. **** There will be an additional charge of $50 for campers requesting a modified diet such as GFCF. This does not apply to life threatening allergies to foods. The additional charge will go toward purchasing the food and a staff person.Make 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 fund raising. We have very limited scholarships available. Stateyour need on an additional page, and your plans 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 Kris at 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 for the coming years. They usuallyrequire us to report feedback from parents. Please check the areas where you saw progress after the2009 session of camp. Then give brief descriptions. thanks!!___ Independence ___ initiation ___ motor skills ___ calm focus/ attention ___ self care___ social ___ self controlComments ___________________________________________________________________________________________________________________________________________________________________________________________________________________________