2010 Fall Adult Camper Application & Questionnaire *indicates a required field First Name* Last Name* Street Address* Address (cont.) City* State/Province* Zip/Postal Code* County Home Phone* E-mail* DOB (MM/DD/YYYY)* Age* Height Weight What is your medical diagnosis ?* How did you hear about W.A.L.H. Camp? Specific volunteer you request to assist you I will provide my own volunteer attendant* yes no maybe will know by (date) If yes, their name and address Friends you wish to bunk near T-shirt size* S M L XL XXL RIDE SHARING Although we cannot guarantee transportation to/from camp we will make every effort to assist you in arranging it.   I need transportation?* Yes No Must remain in wheelchair? Yes No Can transfer from wheelchair? Yes No I can provide a ride?* Yes No Maybe I use a: Car Equipped Van For how many people in wheelchairs? How many ambulatory individuals? Do you have a history of medical problems (pneumonia, diabetes, etc.)?* Yes No If yes, please explain: Do have any drug allergies?* Yes No If yes, please explain: Are you taking prescription medication?* Yes No If yes, please list medication, dosage and frequency of use: List childhood diseases you have NOT had (include chicken pox, measles, mumps, etc.): HEALTH INSURANCE No one will be accepted to camp without having his or her own health insurance coverage. Do you have health insurance?* Yes No If yes, please include name of insurance carrier(s) and policy number(s): FEE SCHEDULE A week of summer camp for an adult camper and volunteer costs upwards of $650. While we do not require you to pay any of this it is our hope that you would either consider a monetary donation or participate in “With A Little Help”, Inc. fundraising activities.   Please select one of the following I choose to make a monetary donation I participated in fundraising I am a first year attendee Other EMERGENCY CONTACT First Name* Last Name* Street Address* Address (cont.) City* State/Province* Zip/Postal Code* Work Phone Home Phone* What is the number one reason your attending W.A.L.H. summer camp? What types of FUN programs and activities would you like available to you at camp? What types of INFORMATIONAL SESSIONS might you attend at camp? Examples include sessions on Living Wills, Independent Living Skills, Understanding Social Security Benefits, etc. What is your favorite food? What are your hobbies and/or interests? Do you enjoy participating in sports (i.e. swimming, long walks, hockey)? Are you employed or do you participate in volunteer activities? If yes, where and please describe the type of work you do. Would you feel more comfortable with your attendant being your companion throughout the day or are you more of an independent person that would rather spend time by yourself and/or socializing with others? What expectations do you have of your volunteer attendant? Describe your daily routine/care plan* What equipment must we supply for you (i.e. Bedboards, etc.): What type of assistance do you require? Dressing* Complete Partial None Eating* Complete Partial None Preparing Meals* Complete Partial None Showering* Complete Partial None Taking Medications* Complete Partial None Toileting* Complete Partial None Transferring* Complete Partial None Turning at night* Complete Partial None Toileting (check all that apply)* Commode Urinal Bedpan None Wheelchair (check all that apply)* Manual Power None Respiratory Aid* Vent BiPap/Cpap None Lift* Yes No Do you require a hospital bed?* Yes No If yes, please explain necessity: Will you bring a service dog to camp with you?* Yes No Will your volunteer attendant require special training to make your week of camp enjoyable and safe (i.e. dressing change, catheter care, respiratory care, etc.)?* Yes No If yes, please explain: Please tell us of anything in particular regarding your needs or comfort in order for us to better accommodate you (i.e. emotional, fears/phobias, special dietary needs/requests, etc.). Please give us any other information about yourself that may be helpful to us in matching you up with a volunteer attendant or suggestions you may have regarding W.A.L.H. Summer Camp. AUTHORIZATION I, hereby attest that the information provided on this application is correct to the best of my knowledge. In the event that the person listed below as an emergency contact cannot be reached in an emergency, I hereby give my permission to the physician selected by the Director or his/her designate, to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for me. I, hereby release and waive any claim or cause of action which may occur against "With A Little Help", Inc. and any volunteer or employee and any other person acting with the permission of either arising out of any injury to my person or property during my stay at Camp, in transit to and from Camp, or during any activity approved by and of said person, and I agree to assume any claim which I might have against any said persons for injury as herein stated.  Further, I consent to "With A Little Help", Inc. using any audio-visual programs, using photographs, or public relations referenced to myself. These may be used for any purpose "With A Little Help", Inc. deem appropriate. FALL CAMP 2010 PARTICIPANT AGREEMENT The mission of "With A Little Help…", Inc. is to provide our participants with a safe and enjoyable experience while attending either our summer or weekend camp. It is our hope that the application and interview process will answer any of your questions as well as help the camp staff determine who you are best suited to be paired with. With that in mind there are also certain expectations we have of both adult campers and volunteers. We ask you to read these expectations and be prepared to follow them if you choose to attend camp. Violations from these expectations may result in you being asked to leave camp. - Once at camp I will not leave. Our insurance policy does not cover any person or persons leaving camp without permission. - I will participate in orientation. This orientation is required of both first-time and veteran adult campers and volunteers. - I will have respect for others and their personal property. - For volunteers – my first responsibility will be that of my adult camper. While we want you to have a good experience, the needs of your camper must come first. If you feel you need some time to yourself, communicate that with your cabin leader or the camp coordinator. - Camp Wawbeek and/or Pioneer Camp rules should be adhered to. Respect their property and avoid secured areas. - Absolutely NO alcohol and/or illegal drugs will be tolerated at camp. Your first offense will result in immediate dismissal from camp and a one year suspension. Your second offense will result in immediate and permanent suspension from attending W.A.L.H. camps. - Most importantly have FUN! – Whether you’re a camper or volunteer use this experience to meet new friends, get involved in activities and go home with the realization that you made a difference in the lives of others. Please also know the important role that both long time adult campers and volunteers play at camp. Along with your cabin leader use them as a resource. Respect them for their experience and use the opportunity to learn from them.   ** By submitting this form, You are agreeing to the terms of the AUTHORIZATION and PARTICIPANT AGREEMENT Created by Thomas Ciufo Copyright © 2010 ["With A Little Help...", Inc]. All rights reserved.