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Ontario Aphasia Camp 2016 Application #:____ Application Form for Person with Aphasia Thank you for your interest in Aphasia Camp 2016! Date: September 23 rd - 25 th , 2016 Location: Tim Horton Onondaga Farms 264 Glen Morris Rd E, St George Brant, ON N0E 1N0 Application: Fill in the application form. Submit by July 31 st to Gemma Woticky. PARTICIPANT INFORMATION Have you attended Aphasia Camp before? 2008 2009 2010 2011 2012 2013 2014 2015 (Retreat Day) 2015 (Full Camp) CONTACT INFORMATION Last Name: First Name: Address: City: Postal Code: Telephone #: Email Address:
Transcript of Application Form -DRAFT - WordPress.com · Web viewall Tim Hortons required forms below. They are...
Ontario Aphasia Camp 2016 Application #:____
Application Form for Person with Aphasia
Thank you for your interest in Aphasia Camp 2016!
Date: September 23rd - 25th, 2016
Location: Tim Horton Onondaga Farms 264 Glen Morris Rd E, St George Brant, ON N0E 1N0
Application: Fill in the application form. Submit by July 31st to Gemma Woticky.
PARTICIPANT INFORMATION
Have you attended Aphasia Camp before?
2008 2009 2010 2011 2012 2013 2014
2015 (Retreat Day)
2015 (Full Camp)
CONTACT INFORMATION
Last Name: First Name:
Address: City: Postal Code:
Telephone #: Email Address:
Date of Birth: Gender: man
woman
Emergency Contact Name: Contact Person’s Phone #:
HEALTH INFORMATION Please circle all that apply.
stroke Seizures brain injury headaches
swallowing digestion diabetes type 1 type 2
pregnant
visionblood pressure
high low angina
heart attackheart disease wear glasses
chronic pain / arthritis
other joint concerns back pain hearing wear hearing aid
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asthma breathing problems incontinence bowel problems
Other:
What else do we need to know about your medical condition?
List your medications (or attach list).
I will need help managing my medications.
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Allergies: yes no
trigger mild moderate severe
wheat
eggs
fish
dairy
peanuts
other nuts
shellfish
soy
Outside : trees, grass, etc.
Insects: bees, wasps etc..
other:
Do you use an EpiPen®? yes no
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Special Diet: yes no
diabetic vegetarian vegan
gluten free low salt dairy free
pureed soft chopped pureed
thickened liquids ( nectar honey pudding)
no pork products
other: _________________________________________________
ACTIVITIES OF DAILY LIVING
NOTE: There will be attendants at the camp available for assistance.
Will you require attendant services during camp? yes no
Are you able to climb stairs safely without assistance? yes no
I will be able to sleep in: the top of a bunk bed
the bottom of a bunk bed
When going to the toilet, I use a:
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raised toilet seat commode grab bars left right
catheter
none of these other: ______________________________
I need help with:
help
activity none some a lot
eating
toileting
showering or bathing
dressing
MOBILITY
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Do you use an assistive device to move around? yes no
If yes, what device do you use?
How much help do you need?
help
device none some a lot
cane
walker
wheelchair
COMMUNICATION
I have difficulty with:
type none some a lot
understanding
talking
reading
writing
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What helps you to communicate? Please circle.
writing drawing communication book
choices iPad or device camera
family or friend extra time gesture
pointing pictures maps
speak slowly boating key words quiet
Other:
PAYMENT
Please enclose cheque or credit card information with this application.
All financial information is confidential and destroyed once payment is processed.
Application will only be processed when payment is received.
Cost: $180 per person
Cheque
Make payable to: March of Dimes Canada
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Credit Card:
Visa MasterCard American Express
IMPORTANT: We will call you for your credit card information upon your
acceptance to camp 2016
Consent
The attendant care staff may help me with my medications.
yes no
If I have a medical emergency, my emergency contact will be phoned.
If they cannot be reached, 911 may be called.
yes no
Photographs, videos, and/or stories of me may be used by: yes no
March of Dimes Canada yes no
Adult Recreation Therapy Centre yes no
Western University yes no
Signature of applicant: Date:
It is important that we have all information.
The Aphasia Camp Planning Committee will review all application so we can meet your medical needs to the best of our ability.
At this time we are unable to provide support
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for some medical conditions.
Send your application and payment to:
Gemma Woticky March of Dimes Canada10 Overlea BlvdToronto, Ontario M4H 1A4
Email : [email protected] : 1 800 263 3463 x 7207
Please note that submitting an application does NOT guarantee acceptance .
Applicants will be notified by mail by mid to late August of their acceptance status.
We will not charge you if you are not accepted.
Please also fill out all Tim Hortons required forms below.
They are not “aphasia friendly” but we need to ask you to complete them to be on Tim Hortons property.
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