RADD 2015 Youth Application

Recreational Activities for the Developmentally Disabled 3131 Taylor Ave., Box #4, Racine, WI 53405 Phone: 262-633-0291 • Fax: 262-633-0299 Email: inf...
Author: Ellen Reynolds
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Recreational Activities for the Developmentally Disabled 3131 Taylor Ave., Box #4, Racine, WI 53405 Phone: 262-633-0291 • Fax: 262-633-0299 Email: [email protected] • Website: www.radd-cpa.org

RADD 2015 Youth Application Client Name: _______________________________ Birth Date: ___ / ____ / _____ Gender: □ Female □ Male Address: _________________________________ City: _____________________ State: _____ Zip: ________ Home Phone: (_______) - _________- ____________ Cell Phone: (_______) - _________- ___________ T-Shirts are sometimes received at events. What size would the client wear? Youth: □ Med □ Lg Adult: □ Small □ Med □ Lg □ X-Lg □ 2X-Lg □ 3X-Lg

Client’s Heritage (Statistics purpose only): □ Asian □ African American □ Caucasian □ Hispanic/Latino □ Native American □ Other Client lives with: □ Both Parents □ Mother □ Father □ Foster Home □ Other: _________________________ Is this the clients first time attending Camp Kinder and/or Youth Respite Overnights? □ Yes □ No Has the client attended any other camp or overnight program before? □ Yes □ No Has the client ever been separated from his or her family before? □ Yes □ No If yes, how was their reaction? ___________________________________________________________ Does the client have any problems with homesickness? □ Yes □ No If yes, do you have any suggestions? ______________________________________________________ _________________________________________________________________________________________ Does the client attend school? □ Yes □ No Where: _________________________ Is the client employed? □ Yes □ No Where: _________________________ What group experience does the client have? ___________________________________________________ ________________________________________________________________________________________ What are the client’s favorite things to do? _____________________________________________________ _________________________________________________________________________________________ Type of Disability (check all that apply) □ Speech □ Hearing □ Visually Impaired □ Cognitive Disability □ Down Syndrome □ Physical Disability □ Autism □ Other (specify) _______________________________________________________ Specialized/Adaptive Equipment (Check all that apply) □ Wheelchair □ Braces □ Crutches □ Canes □ Walker □ Glasses □ Hearing Aid □ Pacemaker □ Scooter □ Other (specify): __________________________

Youth Medical Information (Please check all that apply and explain type, protocol, frequency and any restrictions) □ Asthma □ Allergies □ Diabetes □ Heart Trouble □ Other Type: ____________________________________________________________________________________ Protocol: _________________________________________________________________________________ Frequency: _______________________________________________________________________________ Restrictions: ______________________________________________________________________________ Allergies: _________________________________________________________________________________ Date of last seizure: ______________________________ □ Not Applicable Seizure Disorder: □ Yes □ No Type: □ Tonic - Clonic (Grand Mal) □ Non-Convulsive (Petit Mal) □ Psychomotor □ Nocturnal □ Mixed Typical Seizure Frequency: ___________________ Typical Seizure Length: ____________________________ Known triggers and protocol to follow: _________________________________________________________ _________________________________________________________________________________________ Does client have a history of: Problems With Joints Frequent Colds Heart Disorder or Disease Episodes of Passing Out Bleeding Disorder Blood Disorder Hepatitis A, B, or C Skin Problems (rashes, itching) Emotional Difficulty (seen by a professional) Hospitalizations (explain) Chronic or Recurrent Illness (explain) Surgeries (explain)

Yes

No

Does client have a history of: Problems Sleeping Frequent Headaches Frequent Ear Infections Stomach Disorder Diarrhea Constipation Abnormal Menstrual Cycle Head Injury Other:

Yes No

Doctor’s Name:____________________________________ Phone Number: (______) – _______ - __________ Dentist Name:_____________________________________ Phone Number: (______) – _______ -__________ Hospital Preference:________________________________ Phone Number: (______) – _______ - __________ Medical Information (Please list in case a medical emergency were to arise) Medication

Dosage

Will client need medication administered during Camp Kinder? □ Yes □ No Will client need medication administered during Youth Respite? □ Yes □ No

Time(s)

Transfer Information □ Not Applicable □ Transfers Independently □ Standby Assistance □ Pivot (1 Person) □ Two Person Other/Comments: _________________________________________________________________________ ________________________________________________________________________________________ Toileting □Independent □Needs reminding/assistance □Doesn’t use toilet □Wears diaper/pull-up □Wears pm protection How does he/she let you know they need to use the bathroom? ____________________________________ Does the client use catheterization, enemas, or suppositories? □ Yes □ No _________________________________________________________________________________________ If yes, list times procedure needs to occur _______________________________________________________ _________________________________________________________________________________________ Thoroughly explain procedure that needs to be performed _________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Is the client independent in menstrual care (if applicable)? □ Yes □ No If not, what assistance do they need? ______________________________________________________ Dressing □ Has no difficulty □ Needs Some Assistance □ Needs total Assistance The client can: □ button □ Snap □ Zip □ Tie Shoes Comments ________________________________________________________________________________ _________________________________________________________________________________________ Bedtime Routine Client’s typical bedtime is ___________ Client’s typical waking time is ___________ Does the client need special care at night? □ Yes □ No If yes, describe the care needed: ______________________________________________________________ What is the client’s bedtime routine at home? ___________________________________________________ _________________________________________________________________________________________ Mealtimes Food Allergies: ____________________________________________________________________________ Food Likes: _______________________________________________________________________________ Food Dislikes: _____________________________________________________________________________ Food Restrictions: __________________________________________________________________________ Will client need to be tube fed while attending Camp Kinder? □ Yes □ No Will client need to be tube fed while attending Youth Respite? □ Yes □ No If yes, list times feeding needs to occur: ________________________________________________________ _________________________________________________________________________________________ Thoroughly explain procedure that needs to be performed: ________________________________________ __________________________________________________________________________________________ If client is tube fed, are they allowed additional food or drink by mouth? □ Yes □ No Please explain: _____________________________________________________________________________

Behaviors Bites, Kicks, or Hits others Self Abuse (Hits, Head Bangs, Bites) Verbal Aggression (Yells, Curses, Name Calls) Destruction of Property (Rips, Tips, Throws) Able to control temper Reacts appropriately when frustrated Respects others personal space Waits his/her turn Exhibits inappropriate behaviors due to obsessions

Often

Seldom

Never

Explain

Non-Compliance (Check all that apply) □ Refuse to participate □ Refuse to transition □ Plop on ground to avoid task □ Exhibit reacts to changed routine Self-Stimulating □ Rocks □ Jumps □ Repetition of words □ Repetitive hand movements Does the client wander? □ Yes □ No Does the client have a behavior intervention plan? □ Yes □ No (If yes, please attach a copy with application materials.) What triggers challenging behaviors in client? ___________________________________________________________ _________________________________________________________________________________________________ What are some calming techniques that can be used if client is agitated? ______________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ Independence: □ Has one-on-one in school □ Able to participate in groups of 3 or more without support □ Able to participate in groups of 3 or more with support Communication: Comments: □ Verbal □ Nonverbal ______________________________________________________ □ Understand and follows simple directions _______________________________________________________ □ Consistently expresses his/her needs _______________________________________________________ □ Uses Sign Language _______________________________________________________ □ Uses an augmentive device _______________________________________________________ □ Requires a picture schedule _______________________________________________________ □ Uses a speech board _______________________________________________________ Activities & Additional Information The client: □ Swims well □ Cannot swim, but will go in water □ Unsure of swimming skills □ Fears water Will child need to wear a life jacket at all times? □ Yes □ No Is the client sun sensitive? □ Yes □ No List any outdoor games/activities the client likes: _________________________________________________________ _________________________________________________________________________________________________ List any indoor games/activities the client likes: __________________________________________________________ _________________________________________________________________________________________________

Parent/Caregiver Information Complete this section entirely. RADD needs to reach somebody in case of emergency. Primary Contact #1: □ Parent/Guardian □ Caregiver □ Other: ______________________________________ Name: ________________________________________ Preferred Method of Communication: □ Phone □ Email □ Mail Address: ______________________________________ City: ___________________ State: _____ Zip:_______ Home Phone: (_____) - ______-_________ Cell Phone: (_____)-______-_______ Work Phone: (_____)-______-________ Active Email: _______________________________________________________ Contact #2: □ Parent/Guardian □ Caregiver □ Other: _____________________________________________ Name: ________________________________________ Preferred Method of Communication: □ Phone □ Email □ Mail Address: ______________________________________ City: ___________________ State: _____ Zip:_______ Home Phone: (_____) - ______-_________ Cell Phone: (_____)-______-_______ Work Phone: (_____)-______-________ Active Email: _______________________________________________________ Emergency Contacts List two additional contacts in case the two primary contacts cannot be reached for emergency purposes. Contact 1: Name: ____________________________________________ Relationship: ____________________________ Home Phone: (_____) ______-_________ Cell Phone: (_____)-______-_______ Work Phone: (_____)-______-________ Contact 2: Name: ____________________________________________ Relationship: ____________________________ Home Phone: (_____) ______-_________ Cell Phone: (_____)-______-_______ Work Phone: (_____)-______-________ Financial Information Party responsible for payment of services: □ Self □ Parent/Caregiver □ Fiscal Services Agency □ Other: __________ Name of Fiscal Service: ___________________________________ Case Manager: _______________________________ Phone: (_______) - _________ - _____________ Statistics For the purpose of statistics only, please complete the following: Income (Please check one) □ Below $10,890 □ $10,890 □ $14,710 □ $18,530 □ $22,350 □ $26,170 □ $29,990 □ Above $29,990 Number of individuals residing in home: # of Adults: _________ # of Children: ___________ RADD LIABILITY WAIVER: As a consideration for being permitted to participate in activities sponsored by RADD, also known as the Cerebral Palsy Agency of Racine County, Inc., and/or using equipment, facilities or property of said establishment, such client or user agrees to assume all liability for injury and/or damage resulting from such participation or use and further agrees to hold the Cerebral Palsy Agency of Racine County, Inc. free and harmless on account of any act of omission, commission, or negligence on the part of the Cerebral Palsy Agency of Racine County Inc. or any of their officers, agents, employees or volunteers. RADD may photograph said client together with any subject matter owned by the undersigned, and so hereby authorize the Cerebral Palsy Agency of Racine County Inc. to cause the same to be exhibited as still photographs, transparencies, motion pictures and/or television. The undersigned does hereby release the Cerebral Palsy Agency of Racine Inc. its employees and agents from any and all claims for damages, libel, slander, invasion of the right of privacy, or any other claim based on the use of said material. In the event of an accident or sickness to said individual, the Director may obtain such medical, hospital or surgical assistance and service as he/she may deem necessary, and I/we here agree to pay such charges, indemnify RADD and hold same harmless for such charges. RADD may exchange information it possesses relative to said individual to any qualified agency or doctor, provided such information may be used for purposes of selection only. ________________________________________________ Signature of Parent/Guardian

_____________________ Date