FVSRA Summer Day Camp 2013
Transcript of FVSRA Summer Day Camp 2013
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F V S R A S u m m e r D
a y C a m p
Si x da y ca m ps ha v e b
e en pla nn e d to s er
v e chil dr en a n d you
n g a du l ts wi th s p ecia
l n e e ds, a g es 3
throu gh 3 0. Th e ca m ps a
r e or ga ni z e d by a g e
a n d a bili ty grou ps.
Th e goa ls o f ea ch ca m
p a r e to provi d e
o p por tu ni ti es to e x p eri enc e a va ri e ty
o f r ecr ea tiona l a c t
ivi ti es a n d to a cq u ir
e a n d d ev elo p l eisu r
e skills
whil e en joyin g th e ou
t doors. Ea ch ca m p si t e loca tion ha s a
n in door fa cili ty to
a ssu r e no ca m p ca
nc ella tions
du e to a dv ers e w ea
th er con di tions.
W e ekly th e m es a r e inc
or pora t e d in to ea ch
o f th e ca m ps to o f
f er a va ri e ty o f l eis
u r e a c tivi ti es tha t i
nclu d e
s por ts, ga m es, na tu
r e, dra ma , mu sic, a dv en tu r e a c t
ivi ti es, a r ts a n d cra
f ts, s wi m min g, a g e -a p pro pria t e
fi el d tri ps, visi ts fro
m s p ecia l gu es ts a n d
s p ecia l ev en ts.
Ca m p m e e ts Mon - Thu rs, Ju n e
1 0 -Au g 1. No ca m p Ju ly 4.
Th e su m m er da y ca m
p pro gra m is ba s e d
on th es e fu n da m en t
a ls:
* a n or ga ni
z e d fra m e work
* tra in e d s ta f f
* physica l a n d psycho
lo gica l sa f e ty
* a p pro pria t e s tru c tu
r e
* su p por tiv e r ela tion
shi ps
* o p por tu ni ti es to b e
lon g
* o p por tu ni ti es to ma k e a di f f
er enc e
* o p por tu ni ti es for s
kill bu il din g
* in t e gra tion o f fa m
ily, school a n d co m
mu ni ty
D a y C a m p I n f o r m
a t i o n a l M e e t i n g
Pa r en ts a r e invi t e d t
o a t t en d a n in for ma tiona l m
e e tin g a n d r e gis tra t
ion ni gh t. M e e t th e School S er
vic es
Ma na g er a n d g e t a ll q
u es tions a ns w er e d
firs tha n d.
Tu es, A pril 3 0 fro m
6 - 7: 3 0 PM @ F V S RA
D a y C a m p O p e n H
o u s e
An o p en hou s e is o f f er e d for bo
th pa r en ts a n d ca m
p ers. M e e t th e ca m
p s ta f f who will b e workin g wi th
you r chil d a n d tou r
th e ca m p si t e. Pa r en ts a r e encou
ra g e d to sha r e in fo
r ma tion r e ga r din g a ny
s p ecia l
n e e ds th eir chil d ha
s du rin g this ti m e.
Fri, Ju n e 7 fro m 4 - 6 PM @ ca m p si t
e loca tions
General I nf or ma ti on Re gi s tra ti on I ns truc ti ons Ca mps 4 Sa mpl e Da y 8F or ms
9 -
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Ca mp er’s Guid eA d e t a i l e d l i s t o f c a m p in f o r m a t i o n i n c l u d i n g a c a l e n d a r o f e v e n t s , f i e l d t r ip in f o r m a t i o n , g u id e li n e s a n d r e m in d e r s a b o u t c a m p p r o c e d u r e s w i l l b e a v a il a b l e o n l i n e a t w w w . f v s r a .o r g d u r i n g t h e f i r s t w e e k o f J u n e .
Lunc h & SnackE a c h c a m p e r m u s t p r o v i d e t h e i r o w n l a b e le d s n a c k , s a c k l u n c h a n d b e v e r a g e .
Ca mp T -s hir tE a c h c a m p e r w i l l r e c e i v e a D a y C a m p T - s h i r t . T - s h ir t s a r e w o r n o n a l l f i e l d t r ip s .
Disp ensin g of M edica tionI f a c a m p e r n e e d s t o r e c e i v e m e d ic a t i o n d u r i n g c a m p h o u r s , a 3 1 d a y s u p p l y m u s t b e d e l iv e r e d t o t h e F V S R A o f f i c e b y F r i d a y , J u n e 7 . M e d i c a t i o n m u s t b e d e l iv e r e d i n t h e o r i g i n a l p r e s c r ip t i o n b o t t l e , o r i n c l e a r l y m a r k e d c o n t a i n e r s , w h ic h i n c l u d e t h e c a m p e r ’s n a m e , m e d ic a t io n , d o s a g e , a n d t i m e o f d a y t h e m e d ic a t i o n i s t o b e g i v e n t o t h e c a m p e
r . A p a r e n t / g u a r d ia n m u s t c o m p l e t e t h e P e r m is s i o n t o D i s p e n s e M e d ic a t i o n / W a i v e r a n d R e l e a s e o f A l l C l a im s f o r m , s i g n t h e M e d ic a t io n D i s p e n s in g I n f o r m a t i o n f o r m , a n d p r o v i d e w r i t t e n m e d i c a t i o n d i s p e n s i n g in s t r u c t i o n s ( f o r m s a t w w w . f v s r a . o r g u n d e r “ I m p o r t a n t F o r m s ” ) .
S taffin g Ra tioA n a v e r a g e r a t i o o f 1 s t a f f t o e v e r y 3 c a m p e r s i s m a i n t a i n e d a t c a m p s i t e s . T h e r a t io m a y v a r y a c c o r d i n g t o t h e a b il it i e s a n d f u n c t i o n i n g le v e l s o f t h e c a m p e r s . S o m e c a m p e r s m a y r e qu ir e a h ig h e r r a t i o , s u c h a s 1 :1 o r 1 : 2 . B y g r a n t i n g p e r m is s i o n o n t h e s u m m e r d a y c a m p r e g is t r a t io n f o r m f o r F V S R A t o c o n t a c t y o u r c h i l d ’ s t e a c h e r , F V S R A w i l l b e a b le t o g a in v a l u a b l e i n f o r m a t i o n t o b e s t a s s e s s y o u r c h i l d ’ s n e e d s . A ll d a y c a m p s t a f f p a r t i c i p a t e s i n a n e x t e n s i v e o r i e n t a t i o n w h i c h p r e p a r e s t h e m t o m e e t t h e s p e c i f i c n e e d s o f e a c h c a m p e r . F V S R A m a i n t a i n s t h e r i g h t t o d e t e r m in e f i n a l s t a f f i n g r a t i o s .
Pro gra m S taffS i t e d ir e c t o r s a r e t y p i c a l l y c o l le g e g r a d u a t e s o r u p p e r c l a s s m e n in t h e f i e l d o f T h e r a p e u t ic R e c r e a t io n ,S p e c ia l E d u c a t io n o r a r e l a t e d f i e l d . T h e s i t e d ir e c t o r s a r e t h e o n - s i t e s u p e r v i s o r s o f t h e p r o g r a m a n d m u s t h a v e n o n v i o l e n t C r is i s I n t e r v e n t io n T r a in in g ( C P I ) , C P R a n d F i r s t A i d C e r t i f i c a t i o n . D a y c a m p s t a f f e r s a r e t e a c h e r s , t e a c h e r a s s is t a n t s , c o ll e g e g r a d u a t e s , a n d c o l l e g i a n s w o r k in g o n d e g r e e s in T h e r a p e u t i c R e c r e a t i o n , S p e c i a l E d u c a t io n , A d a p t iv e P h y s i c a l E d u c a t i o n o r a r e l a t e d f i e l d , a s w e l l a s m a t u r e h ig h s c h o o l s t u d e n t s . S t a f f m a y w o r k o n e - o n - o n e w it h a p a r t i c i p a n t o r m a y b e r e s p o n s i b l e f o r a g r o u p o f p a r t ic i p a n t s .
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R e gi s tr a ti o nEa ch Ca m p is limi t
e d to a ma ximu m nu mb e r o f ca m pe rs.
Ea rly re gis tra tion is im por ta n t for a c
ce p ta nce
to ca m p. Re gis tra tions will b e proce ss
e d on a “Firs t Come , Firs t S e rve d ” b a
sis, wi th pre fe re nce give n to
re side n ts o f FVS RA M e mb e r A ge ncie s.
Find forms on pa ge s 9 -1 2.
Ea rly Bird Re gis tra tion: Fri, M a y 10
Re gu la r Re gis tra tion: Fri, M a y 2 4
L a te Re gis tra tion De a dline : Fri, M a y 31
Pl e a s e n o t e, o ur r e gi s tr a ti o n pr o c e s s h a s c h a n g e d t o pr ovi d e a n e ar
l y bir d di s c o u n t .
* Re gis te r b y M a y 10 to re ce ive th e e a rl
y b ird discou n t ( $ 2 5 re du c tion in ca m p fe e ) .
* Re gu la r re gis tra tion de a dline is M a y 2
4.
* Ca m pe rs mu s t re gis te r a t le a s t 10 da
ys prior to s ta r tin g ca m p in orde r to
me e t tra ns por ta tion
ne e ds a nd e nsu re th e ove ra ll sa fe ty a n
d su cce ss o f th e ca m p e x pe rie nce .
* Pa r tici pa n ts ma y e nroll b y th e we
e k , a comb ina tion o f we e k s or a ll e i gh t
we e k s. FVS RA will u se i ts
discre tion to pla ce pa r tici pa n ts b a se d
on th e ir ne e ds a nd FVS RA ’s re sou rce
s.
* Re gis tra tion con firma tion will b e ma ile
d to th e ca m pe r’s h ome . Ple a se no te s
ta tu s on th e con firma tion.
I f pro gra m s ta tu s is o th e r th a n “E ” ( e
nrolle d ) , a n FVS RA s ta f f me mb e r will
ca ll.
* Ple a se no te th a t re side n t ca m pe r
re gis tra tions ta k e priori ty ove r non -re s
ide n t re gis tra tions.Non -
re side n t re gis tra tions will b e proce sse
d a f te r th e M a y 2 4 de a dline .
* Re gis te r ca re fu lly! In th e e ve n t th a t i t
is ne ce ssa ry to a l te r a ca m p re gis tra t
ion a f te r i t h a s b e e n
re ce ive d a t FVS RA , th e re will b e a $1 5 ch a r ge for a ny ch
a n ge to th e re gis tra tion.
S c h ol ar s hi p I n f or m a ti o n
FVS RA h a s sch ola rsh i ps a va ila b le to r
e side n ts wi th fina ncia l limi ta tions. Pa re
n ts or gu a rdia ns in te re s te d
a re re q u ire d to com ple te a sch ola rsh i p
a p plica tion form a nd su b mi t a $ 2 5 non
-re fu nda b le fe e ( a p plie d to
th e pro gra m fe e ) .
Tr a n s p or t a ti o n Tra ns por ta tion - - pr
ovide d b y Firs t S tu de n t - -is Door to Do
or only a nd is a va ila b le to ca m pe rs w
h o re side
wi th in th e b ou nda rie s o f th e Fox Va lle
y, Ge ne va , S t. Ch a rle s, Ba ta via , S u ga r
Grove , Oswe gola nd Pa rk
Dis tric ts a nd th e Villa ge o f S ou th El gin
. Rou te s a re s tre a mline d to k e e p tri ps
a s close to 4 5 minu te s
or le ss a s possib le . Indica te tra ns por t
a tion ch oice on th e re gis tra tion form. T
h e tra ns por ta tion se rvice
will pick u p ca m pe rs a t th e ir h ome , ta k e th e m to ca m p, a nd r
e tu rn th e m to th e ir h ome or a consis te
n t
loca tion de si gna te d b y a pa re n t / gu a rdi
a n.
E arl y bir d r e gi s tr a n t s r e c eiv e
a $ 2 5 di s c o u n t !
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3-6 years L il’
Stars
Campers ages 3 to 6 acquire knowledge and play in ways that are significantly different from how older children learn. Staff at Stars organize camp keeping in mind that younger children learn best through direct sensory encounters with their world and by maexploring and experimenting. A consistent schedule is followed from day to day, allowing campers to build trust in the environmeearn a basic sense of time; recognizing what comes first in the day, second, next and last. Summer day camp activities include a coof both passive and active activities in group and individual play settings. Arts and crafts, creative drama, games, music, sports andare all part of the summer day camp experience designed to promote use of--and growth of--cognitive, physical, communication skills. Outings and special guests are planned to enrich community awareness and experience new recreation opportunities.
Dates: Mon-Thurs, June 10-Aug 1. No Camp July 4. Parent Open House: Fri, June 7 from 4-6 PM at camp site
Camp Lil’ StarsIntended for campers ages 3-6 from all FVSRA service areas.
Time: 8:30 AM - 2 PM Location: Pottawatomie Community Center, St. Charles
Swimming Facility: Swanson Pool, St. Charles
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Camp Rising Stars and Camp Shining Stars allow campers to become more independent while building self-esteem and confidenabilities. Each camper will participate in a diverse set of age-appropriate activities that build skills in developing areas and leisencourage campers to participate in every planned activity using creative motivational tools and lead the group with fun, rewardCampers will fulfill certain rotating responsibilities such as line leaders, lunch clean-up and team leaders. Staff focus on positive reinn a non-competitive environment, coordinating activities that are intrinsically rewarding including: creative arts, dance, movement askill building. A focus on team building and collaborative skills are implemented during team sports and games at the camp site, anhe pool. Special guest and group outings teach overall safety and community awareness.
Dates: Mon-Thurs, June 10-Aug 1. No Camp July 4.
Parent Open House: Fri, June 7 from 4-6 PM at camp site
Camp Rising Starsntended for campers ages 7-12 in the northern FVSRA servicearea (South Elgin, St. Charles, Geneva and Batavia).
Time: 9 AM - 2:30 PM Location: Rotollo Middle School, Batavia Swimming Facility: Sunset Pool, Geneva
Camp Shining StarsIntended for campers ages 7-12 in the southern FVSRAarea (Oswegoland, Sugar Grove and Fox Valley area).
Time: 8:30 AM - 2 PM Location: South Point Center, Oswego Swimming Facility: Oswegoland Aquatic Park, Montgomery
Rising Stars andShining Stars7-12 years
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All Stars and Rock
Stars
13-21 year
Camp All Stars and Camp Rock Stars encourage each camper to thrive in a group environment and the community. Camp prenvironment for campers to make friends, lower social anxiety and develop peer relationships. Planned activities challenge campnew things and gain new skills. Campers will play a part in decision making during group choice periods, and will have input on actoutings planned during the course of camp. These activities include: adventure exploration, environmental awareness and the proproblem solving and physical skills. Playing an active role in the community during outings offers a chance to cultivate social skills. Aswimming safety and skill-based games make trips to the pool safe and successful for everyone!
Dates: Mon-Thurs, June 10-Aug 1. No Camp July 4.
Parent Open House: Fri, June 7 from 4-6 PM at camp site
Camp All Starsntended for campers ages 13-21 in the northern FVSRA servicearea (South Elgin, St. Charles, Geneva and Batavia).
Time: 9 AM - 2:30 PM Location: Persinger Center, Geneva Swimming Facility: Sunset Pool, Geneva
Camp Rock StarsIntended for campers ages 13-21 in the southern FVSRAarea (Oswegoland, Sugar Grove and Fox Valley area).
Time: 9 AM - 2:30 PM Location: Fearn Elementary School, North Aurora Swimming Facility: Splash Country, Aurora
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Beyond the Stars provides purposeful activities, independent living skills and continuing education within the traditional summer setting for campers ages 22 to 30. Campers will develop new skills in cooking and nutrition, money handling, safety and problem sprogramming specifically designed for young adults. Each day offers campers opportunities to socialize through peer interaction; manguage and communication skills while developing new friendships.
Beyond the Stars offers exposure to new leisure and fitness options including sports skills, motor development, aerobic workoutscrafts, music, games and community awareness when visiting FVSRA member agency park and recreation resources. Activities incoutings, special guests and group projects. Campers are sure to stay engaged, active and involved in the community all summer lo
variety of outings and volunteer projects!
Dates: Mon-Thurs, June 10-Aug 1. No Camp July 4. Parent Open House: Fri, June 7 from 4-6 PM at camp site
Camp Beyond the StarsIntended for campers ages 22-30 from all FVSRA service areas.
Time: 9 AM - 2:30 PM Location: The Annex, South Elgin
Swimming Facility: Swanson Pool, St. Charles
22-30 years
Beyond
the Stars
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S a m pl e D a y
1. A rriva l & fre e ch oice s ta tions
2. A t te nda nce
3. Circle time or cu rre n t e ve n ts
4. L a r ge grou p ga me
5. S ta tions in sma ll grou ps
6. A r ts a nd cra f ts
7. Na tu re 8. S ma ll grou p ga m
e
9. Fi tne ss or gross mo tor a c tivi t y
10. L u nch
11. Pre pa re for pool
1 2. Bu s to pool
1 3. S wim & ga me s
1 4. Bu s to ca m p
1 5. A f te rnoon sna ck s
16. Closin g a c tivi tie s & son gs
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Participant Name: __________________________________________________________________Age: ____________________________
Please CIRCLE Camp/Program For Ofce Use ONLY
Camp/Program Name Sch Awd D/C/N Date Ck# Amt B
Lil’ Stars
Rising Stars Shining Stars
All Stars Rock Stars
Beyond the Stars
Please CIRCLE registration choice(s)
TRANSPORTATION IS DOOR TO DOOR. Please provide information regarding pick-up and drop-off location and contact.
Contact Name: _________________________________________ Relationship: ___________________ Phone #: _____________________
Pick-Up Street Address: _________________________________________________________________ City/Zip: _____________________
Drop-Off Street Address: ________________________________________________________________ City/Zip: _____________________
Emergency Contact: ____________________________________ Relationship: ___________________ Phone #: _____________________
PAYMENT — PAYMENT IN FULL IS REQUIRED FOR REGISTRATION. Total Camp Fees Due: ___________________________
IF PAYING BY CREDIT CARD: Visa MasterCard
Credit Card Number: ________________________________________________Expiration Date: __________________________________
Card Holder Signature: ______________________________________________________________________________________________ (REQUIRED for credit card payment)
I grant FVSRA permission to contact participant’s teacher.
School Name: _________________________________________________________________________________________________
Teacher Name: ________________________________________________________________________________________________
Phone #: _______________________________________Email: ________________________________________________________
T-Shirt Size:
NOTE: When registering by FAX, it is mutually understood that the facsimile registration document (including the Waiver & Release of All Claims) shall suand have the same legal ef fect, as the original form.
FVSRA Summer Day Camp 2013 Registration ForBE SURE TO COMPLETE AND SIGN THE OTHER SIDE OF THIS FORM.
PERMISSION TO GATHER ADDITIONAL INFORMATIONI give permission to release information from this registration form and gather additional informat
professionals that would possibly enhance the participant’s recreational involvement. All information wil
confidential.
Participant’s Signature: X _________________________________________________________________________
(18 years or older or Parent/Guardian)
Adult Sm Med LG XLG 2XL 3XL
Child Sm Med LG
O P T I O N A L
Week(s)
Early BirdRegistration
(Deadline 5/10) w/ Trans
Early BirdRegistration
(Deadline 5/10) No Trans
Res/Non-Res
RegularRegistration
(Deadline 5/24) w/ Trans
RegularRegistration
(Deadline 5/24) No Trans
Res/Non-Res
Late RegistrationDeadline
Late Registration(After 5/24)
w/ Trans
Late R(Af
NRes
June 10 - August 1(All 8 weeks)No Camp Wed. July 4
$1998 $998/2535 $2023 $1023/2560 Fri, May 31 $2048 $10
June 10 - June 13 $269 $137/335 $294 $162/360 Fri, May 31 $319 $1
June 17 - June 20 $269 $137/335 $294 $162/360 Fri, June 7 $319 $1
June 24 - June 27 $269 $137/335 $294 $162/360 Fri, June 14 $319 $1
July 1 - July 3No Camp Thurs. July 4
$202 $103/251 $227 $128/276 Fri, June 21 $252 $1
July 8 - July 11 $269 $137/335 $294 $162/360 Fri, June 28 $319 $1
July 15 - July 18 $269 $137/335 $294 $162/360 Fri, July 5 $319 $1
July 22 - July 25 $269 $137/335 $294 $162/360 Fri, July 12 $319 $1
July 29 - August 1 $269 $137/335 $294 $162/360 Fri, July 19 $319 $1
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Participant’s Name:___________________________________________________ Date: ________________ (Print)
Participant’s Signature: X __________________________________________________________________ (18 years or older or Parent/Guardian)
Sign & DateWaiver Here
R E Q U I R E D
PARTICIPATION WILL BE DENIED IF THE SIGNATURE OF ADULT PARTICIPANT OR PARENT/GUARDIAN IS NOT ON THIS W
IMPORTANT INFORMATIONhe Fox Valley Special Recreation Association (FVSRA) is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants
he FVSRA continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participants’ safety. Howeve
nd parents/guardians of minors registering for this program/activity must recognize that there is an inherent risk of injury when choosing to participate in recreational activiti
ou are solely responsible for determining if you or your minor child/ward are physically fit and/or skilled for the activities contemplated by this agreement. It is always advisabl
he participant is pregnant, disabled in any way, or recently suffered an i llness, injury, or impairment, to consult a physician before undertaking any physical activity.
WARNING OF RISKRecreational activities/programs are intended to challenge and engage the physical, mental, and emotional resources of each participant. Despite careful and proper preparatio
medical advice, conditioning, and equipment, there is still a risk of serious injury when participating in any recreational activity/program. Understandably, not all hazards and
e foreseen. Depending on the activity, participants must understand that certain risks, dangers, and injuries due to inclement weather, slipping, falling, poor skill level or
arelessness, horseplay, unsportsmanlike conduct, premises defects, inadequate or defective equipment, inadequate supervision, instruction or officiating, and all other c
nherent to indoor and outdoor recreational activities/programs exist. Participants must understand that certain risks, dangers, and injuries due to acts of God, inclement wea
alling, equipment failure, failure in supervision, premises defects, and all other circumstances inherent to recreational activities/programs exist. In this regard, it must be rec
s impossible for the FVSRA to guarantee absolute safety.
WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISKPlease read this form carefully and be aware that in signing it and participating in the FVSRA Summer Day Camp 2013 activities, you will be expressly assuming the risk and
nd waiving and releasing all claims for injuries, damages or losses which you or your minor child/ward might sustain as a result of participating in any and all activities conne
ssociated with this program/activity (including transportation services/vehicle operation, when provided).
recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, and I voluntarily agree to assume that full risk of any and all inju
r loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/w
or accrue to me or my child/ward) as a result of participating in this program/activity against the FVSRA, including its officials, agents, volunteers and employees (hereinafte
eferred as “FVSRA”).
do hereby fully release and forever discharge the FVSRA from any and all claims for injuries, damages, or losses that my minor child/ward or I may have or which may accru
minor child/ward and arising out of, connected with, or in any way associated with this program/activity.
understand the FVSRA may photograph/videotape the events or activity in which I am (or my child/ward is) participating. I give my permission for the FVSRA to use photograph
f me (or my child/ward) for the purpose of promoting the FVSRA and its services/programs. I give my permission with the following understanding: No compensation of any kin
o me (or my child/ward) at this time or in the future for the use of my (or my child/ward’s) likeness. If extenuating circumstances prohibit the use of my (or my child/ward’s) lik
nitial here ________
n the event of an emergency, I understand and authorize FVSRA staff and of ficials to secure from any licensed hospital, physician and/or medical personnel any treatment deem
or immediate care for myself or minor child/ward and agree that I will be responsible for payment of any and all medical services rendered.
have read and fully understand the above Important Information, Warning of Risk, Waiver, and Release of All Claims and Assumption of Risk. If registering a minor participant, I
hat I have read the above to my minor child/ward. If registering by fax, your facsimile signature shall substitute for and have the same legal ef fect as an original form signatur
FVSRA Summer Day Camp 2013 Registration Waiv
Participant Name: __________________________________Age: ________Birthdate: _______________Sex: ________ Ethnicity: ___________(for statistical
Home Address:_________________________________City: ______________________Park District: __________________________ Zip: ____
Primary Home #: _______________________________________________
Father/Guardian Name: _________________________________________Cell #: __________________________Work # _________________
Mother/Guardian Name: ________________________________________Cell #: __________________________Work #: _________________
would like to receive FVSRA program and news updates via email. Email Address (print clearly): ___________________________________
would like to donate to the FVSRFoundation. Please accept my donation of $ _______________
Registration deadline for residents is Friday, May 24. Non-resident registrations will be processed after May 24.
Fox Valley Special Recreation Association
2121 W. Indian Trail • Aurora, IL 60506
Ph: 630.907.1114 • F: 630.907.1116 • www.fvsra.org
Will participant be responsible for self-medication? Yes
Will staff need to administer medication? Yes
Is participant requesting a scholarship? Yes
s this a new address? Yes No
s this a new phone number? Yes No
s this a new participant? Yes No
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Annual Information FormForm Valid June 1, 2013 - May 31, 2014
General Information
Medical Information
Participant Information PLEASE COMPLETE EACH SECTION AND PRINT CLEARLY
Name _____________________________________Age __________ Birthdate _________ Sex ___________ Ethnicity _________
Home Address ______________________________City ________________________________State _________ Zip __________
Phone # ___________________________________Park District _________________________Township____________________
School/Work _____________________ Phone# __________________ Teacher/QSP _________________ Phone # _____________Doctor _____________________________________Phone # _____________________
Parent/Guardian Information PRINT CLEARLY
Father’s Name _______________________Cell # ________________ Work # _________________E-mail ____________________
Mother’s Name_______________________Cell # ________________ Work # _________________E-mail ____________________
Emergency Contact
Name ____________________________________________ Relationship _____________________ City _____________________
Home # ________________________________ Cell # ______________________________ Work # _________________________
□ Aging Disorders
□ Arthritis □ Attention Decit Disorder □ Attention Decit Hyperactivity Disorder □ Autism □ Behavior Disorder □ Cerebral Palsy □ Developmental Disability □ Down Syndrome
□ Early Childhood Delays
□ Educable Mental Handicap □ Emotionally Disturbed □ Epilepsy □ Fetal Alchohol Syndrome □ Hearing Impairment □ Learning Disorder □ Mental Illness □ Multiple Sclerosis
□ Multiply Challenged
□ Physical Disability □ Trainable Mental Handicap □ Traumatic Brain Injury □ Sensory Integration Dysfunctio □ Severe Mental Handicap □ Speech & Language Delay □ Visual Impairment □ Other ____________________
Atlanto Axial Instability? If participant has Down Syndrome, does s/he have Atlanto Axial instability diagnosis? □ N/A □
Surgeries? Has participant had any injuries or surgeries in the past year? □ No □ Yes (please describe) ________________________
Wheelchair? □ No □ Yes (manual/electric) ____________________________________________________________________
Does participant need assistance with transfers? □ No □ Yes (gait belt, hoyer, etc.) _________________
Seizures? □ No □ Yes (please attach seizure information sheet)
Allergies? □ No □ Yes (please describe) _____________________________________________________________________________________
Shunts? □ No □ Yes (please describe) _____________________________________________________________________________________
Dietary Needs? □ No □ Yes (please describe: i.e. diabetes, gluten-free, casein-free, G-tube, etc.) __________________________________________
Medication PLEASE LIST ALL MEDICATIONS PARTICIPANT IS TAKING, EVEN IF IT WILL NOT BE DISPENSED DURING PRO
Drug Name ________________________________________ Dosage __________________ Frequency ________________
Drug Name ________________________________________ Dosage __________________ Frequency ________________
Drug Name ________________________________________ Dosage __________________ Frequency ________________Attach sheet with additional medications, if needed.
Check if stated on medication bottle(s): □ Drink plenty of water
□ No direct sunlight
□ Take with food
□ May cause heat sensitivity
□ May cause drowsiness
□ Other __________________
Will participant be responsible for self medication during any program(s)? □ No □ Yes
Will staff need to remind participant to take medication? □ No □ Yes
R E Q U I R E D
Disability Information PLEASE INDICATE PRIMARY DISABILITY WITH A “1” AND SECONDARY WITH A “2.”
for statistic
Communication
NDICATE METHOD(S) OF COMMUNICATION.
Participant communicates... □ verbally □ sign language □ Boardmaker □ other (explain) _______________________
Assisted Devices
NDICATE ASSISTED DEVICE(S) USED.
□ Hearing aid
□ Glasses
□ Orthopedic devices
□ Prosthetic Devices
□ Walker
□ Cane
□ White cane
□ Canadian crutches
□ Other ____
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Interaction/Socialization Skills
Behavior
Safety & Recreation
Goals
NDICATE SOCIAL INTERACTION/SOCIALIZATION SKILLS. CHECK THE ANSWER THAT BEST APPLIES.
The participant...
nitiates social interactions □ on his/her own □ with verbal prompting □ avoids social interactions (explain) _________________
___________________________________________________________________________________________________________
Prefers being □ alone □ with peers □ with adults (explain) _____________________________
___________________________________________________________________________________________________________
s most successful in □ large groups □ small groups □ other (explain) __________________________________
___________________________________________________________________________________________________________
Does the participant...
Act out (verbally, physically, etc.) □ No □ Yes (explain)____________________________________________
Respond to specic behavior techniques? □ No □ Yes (explain)____________________________________________
Respond to any incentives to encourage participation? □ No □ Yes (explain)____________________________________________
Need assistance with transitions? □ No □ Yes (explain)____________________________________________
Wander/run from groups? □ No □ Yes (explain)____________________________________________
Please list any sensory issues the participant may have: ____________________________________________________________
___________________________________________________________________________________________________________
NDICATE REASON(S) FOR PARTICIPATION. CHECK ALL THAT APPLY.
□ Physical activity
□ Socialization/friendships
□ Group interaction
□ Skill development
□ Motor development
□ Creativity/self-expression
□ Self-esteem/condence
□ Responsibility
□ Entertainment
□ Other ____________________
Please identify any specic goals parents/guardians would like to see worked on: ______________________________________
___________________________________________________________________________________________________________
FVSRA provides an approximate 1:4 staff to participant ratio.f participant would like to request a closer ratio, please explain why: _________________________________________________
Can participant...Be left alone after a program has ended to wait for a ride? □ No □ YesGet home independently from a program (i.e. walk, take public transportation, etc.)? □ No □ YesSwim? □ No □ Yes
Indicate otation device(s) owned or needed by participant ____________________________________________________
R E Q U I R E D
Signatures I attest that this information is true and accurate to the best of my knowledge and I will notify FVSRA of any cin the above information.
_____________________________________________________________ _________________________
Signature of person completing form Date
Daily Living SkillsFull Moderate Independent Details
What level of assistance does participant need with...
Eating/Drinking (cut food, uses straw, etc.) □ □ □ ____________________________Dressing/Undressing (tying shoes, pulling up swim suit, etc.) □ □ □ ____________________________Toileting (diapers, catheter, wiping, etc.) □ □ □ ____________________________Money handling (monitor for correct change, no concept, etc.) □ □ □ ____________________________Following directions (single step, repetition, visual cues, etc.) □ □ □ ____________________________Safety (crossing street, water safety, etc.) □ □ □ ____________________________Reading (comprehension level, etc.) □ □ □ ____________________________Writing (legibility, words/sentences, etc.) □ □ □ ____________________________Responsibility (keeping track of belongings, etc.) □ □ □ ____________________________
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n August 2012 FVSRA teamed with the naonal organizaon Lose the Training Wheels (now iCan Shine) to teach children with sp
needs how to ride a convenonal, two-wheel bike during a week-long camp.
By the end of camp, over 70% of the 24 parcipants were able to ride their own two-wheel bike independently without the need
raining wheels or other adapve equipment.
FVSRA will host a second Lose the Training Wheels bike camp this summer, August 12-16. To learn more about the camp, including
egister, please contact FVSRA bike camp coordinator, Heather Richardson, at (630) 907-1114 x 1212 or [email protected].
Ben was discouraged because he felt too old fortraining wheels. That stopped him from practicing.This program totally got him over the hump!” -Greg Pardue
“Prior to camp, Ian would always choose his scoowas very fearful. Now he is riding his two-wheeleall by himself with a huge smile on his face.”--Jenny Fergus
Lose the Training Wheels Bike Cam
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PRSRT ST
US POSTA
PAID
PERMIT NO
FOX VALLE
POSTMASTE
DATED MATER
PLEASE DO NO2121 W. Indian TrailAurora, IL 60506
Phone: (630) 907-1114Fax: (630) 907-1116www.fvsra.org
f you would like to stop receiving this
brochure, please call the FVSRA ofcend ask to be taken off the mailing list.
Lose the Training
Wheels Bike CampThis summer, FVSRA is partnering with iCan Shine to
remove barriers AND training wheels!
Parcipants of the FVSRA Lose the Training Wheels bike
camp will learn to ride a standard two-wheel bike without
the need for training wheels or adapve equipment.
SEE REVERSE FOR DETAILS!