Camp “Kids First”
PARTICIPANT INFORMATION FORM
Kids just being kids!
Camp “Kids First”
Participant Information
COST $200.00 ($50.00 REQUIRED AT TIME OF REGISTRATION)
Payment can be made by cash or cheque only.
Fort McMurray Autism Support Group
141-400 Silin Forest Road
Fort McMurray, AB T9H 3S5
Phone: 780-799-2751
Email: [email protected]
Week 1 – July 10-14 ages 4 to 7. Week 2 – July 17-21 ages 8 to 11. Week 3 – July 24-28 ages 12 to 18.
**Organizers will coordinate a week with family based on accommodating as many registrants as
possible**
PARTICIPANT’S NAME:
Parent/Guardian 1 (Main contact – responsible adult living with participant):
Last name:
First name:
Relationship to participant:
Street:
City:
Province:
Postal Code:
Home phone number:
Work phone number:
Cell phone/pager:
E-mail: (required)
Fax number:
Summer / Other Phone number:
Primary Language:
Secondary Language:
Do you have a family member or friend who can interpret for you? If yes, please provide their name and
telephone number.
Camp “Kids First” Registration
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
Parent/Guardian 2 (If applicable):
Last name:
First name:
Relationship to participant:
Street:
City:
Province:
Postal Code:
Home phone number:
Work phone number:
Cell phone/pager:
E-mail:
Fax number:
Emergency Contact #1 (Must not be in the same household):
Last name:
First name:
Home phone number:
Work phone number:
Cell/pager number:
Relationship to participant:
Emergency Contact #2 (If available):
Last name:
First name:
Home phone number:
Work phone number:
Cell/pager number:
Relationship to participant:
T-SHIRT SIZE- INDICATE ADULT OR YOUTH SIZE ____________
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
PARTICIPANT INFORMATION
Participant Profile :
Year
First Name:
Birthdate (please write out):
2017
Last Name:
Gender:
E-mail Address:
Name of participant’s school (currently attending):
Grade/Level:
EEP to Grade 2
Grade 3 to Grade 6
Grade 7 to Grade 9
Grade 10 to Grade 12
Disability and Medical Information:
Primary Disability:
Secondary Disability:
Ie: Angelman Syndrome, Aspergers Syndrome, AD/HD, Autism, Brain Injury, Cerebral Palsy,
Developmental Disability, Down Syndrome, FAES, Fragile X, Learning Disability, None, Other,
PDD, Spina Bifida, Turner Syndrome, Undiagnosed, etc…
Please describe the participant’s disability(ies):
Ratio (see next page for descriptions of ratios):
Alberta Health Care #:
Doctor’s Name:
Doctor’s Phone Number:
Date of last tetanus shot:
Medical Conditions:
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Camp “Kids First”
Allergies:
PARTICIPANT INFORMATION FORM
Allergy Kit Carried? :
Please assess the level of support (Ratio) you feel the participant requires and enter the ratio
above:
Ratio
Participant Profile




Independent participant.
1:6
Requires minimal supervision, occasional reminders.
Requires & responds to verbal prompts & reminders.
May require assistance with activities of daily living (toileting, eating, etc.) but this is short-term
1:4
support.
 Will join short-term activities.
 Close supervision required.
1:2
 Responds to verbal prompts; will do activities when settled.
 Needs support during transitions, and may require 1:1 support on a short-term basis.
 Will not remain with the group, either leaving intentionally, or has no desire to stay with the group.
 Without constant supervision could be a safety risk to themselves or others.
1:1
 May exhibit aggressive behaviour to others.
 Wanders or runs away.
 Requires specialized ongoing personal and/or medical care.
* Aides are required for participants with a 1:1 ratio
If the participant is currently taking any medication, whether at home or during Camp “Kids
First” time, please complete the following information:
Medication Type:
Times to administer:
Dosage:
Storage:
Special Instructions:
Medication Type:
Times to administer:
Dosage:
Storage:
Special Instructions:
Medication Type:
Times to administer:
Dosage:
Storage:
Special Instructions:
Camp “Kids First” Registration
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
Please note any technical aides the participant makes use of:
Wheelchair:
Braces/Crutches/Walker:
PECS:
Braille:
Sign Language:
Hearing Aid:
Other (please describe):
Does the participant have a history of seizures?
Yes
No
If yes, please describe the following: pattern, duration, specific considerations, triggers,
aftercare, etc.
Please provide us with any information you feel would prove helpful to our staff in providing
the best possible experience and care for your participant:
Is there any specialized behavior management program that is being used at home, school or
otherwise? Please describe the specialized behavior management program: (please attach
any additional information that may be helpful)
Please indicate (circle) the level of personal assistance the participant requires for the
following:
Eating/Drinking
1
2
3
4
Toileting
1
2
3
4
Dressing
1
2
3
4
Personal Hygiene
1
2
3
4
Mobility
1
2
3
4
1 = Totally Independent, 2 = Needs Prompting, 3 = Needs Some Help, 4 = Total Assistance.
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
Does the participant display any of the following behaviors?
Physical Aggression? Yes
No
Running/Wandering? Yes No
Verbal Aggression? Yes
No
Communication Difficulties? Yes No
If the answer to any of the above is yes, please describe:
Will a personal care attendant (aide) be accompanying the participant to the programs or to
Camp “Kids First”? (If using private aide, liability waiver must be signed)
Yes No If yes, please supply the following:
Aide’s Name:
Aide’s Phone Number:
Agency Name (if applicable):
Agency Phone Number:
What method(s) of transportation will the participant use to get to and from camp
Parent/Guardian
Transit
Other? (Please describe):
Is there anything else we should know?
To the best of my knowledge, the above information is accurate and complete. Should
anything change, I understand that Camp “Kids First” will be notified.
Signature:
Camp “Kids First” Registration
Date:
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
Please provide any additional information above; please include food preferences and sensory needs
in any. What reinforcers are used with your child? Please attach behavior plan if available.
Camp “Kids First” Registration
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
THE CAMP “KIDS FIRST” APPLICATION AND RELEASE
No person shall participate in any activity provided by CAMP “KIDS FIRST” unless this agreement is
properly executed, such execution forming part of the consideration of participation.
Release
In consideration of participation in any program, event, or activity sanctioned by Camp “Kids First”, the
undersigned participant, parent or guardian understands and agrees that the participant does so at
his/her own risk and that Camp “Kids First” in partnership with McMan Youth Services, its employees,
officers, directors, agents, volunteers, and other participants will not be liable to anyone in contract,
negligence, or otherwise, for any losses, damage or injury to person or property resulting from, or
occurring in connection with Camp “Kids First” activities. Without limiting the generality of the foregoing,
Camp “Kids First” activities include motor boat ride, swimming, and transportation, when part of the
program, to and from Camp “Kids First” activities.
Indemnification
The undersigned further agrees to completely indemnify Camp “Kids First” in partnership with McMan
Youth Services for any expenses or liabilities incurred as a result of any injury or other loss to the
participant including, without restricting the generality of the foregoing, the costs of ambulance or
emergency services and related costs.
Representations as to Medical History of Participant
The undersigned knows of no physical or emotional reason why the participant should not participate
in any Camp “Kids First” activity. The undersigned also represents that full disclosure of the
participant’s medical history has been made to Camp “Kids First”.
Representations as to Authority of Signatory
If the participant is under 18 years of age, the undersigned parent or guardian hereby grants this release
on his or her own behalf and on behalf of the participant. The undersigned further represents that he
or she has read and understood this Release and, in the case of a parent or guardian, has full authority
to execute this release on behalf of the participant.
_____________________________________
Signature of Participant (if over 18 years) and
Own Guardian OR Parent/Guardian
_______________________________
Printed Name of Signatory
_____________________________________
Signature of Witness
_______________________________
Printed Name of Witness
__________________________________________
Date
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
PRESCRIPTION AND NON-PRESCRIPTION MEDICATION RELEASE
NOTE: POSITIVELY NO NON-PRESCRIPTION (ie: Tylenol) OR PRESCRIPTION DRUGS WILL
BE ADMINISTERED TO ANY PARTICIPANT IF THE MEDICATION RELEASE IS NOT SIGNED.
When the Release is signed, non-prescription drugs will ONLY be administered following
verbal permission by the parent/guardian.
I hereby request and grant permission for Camp “Kids First” and partners to administer medication
to_______________________________ as indicated in the Medication Information section of this
form or as otherwise requested by me.
_______________________________ ______________________________
Signature of parent/guardian
Date
_______________________________ ______________________________
Signature of witness
Date
PERMISSION FOR PHOTOGRAPHY
As the parent/guardian of ___________________________________, I hereby give Camp “Kids First”
permission for my child to be photographed. I understand that the photographs may be used in
visual presentations (including newsletters, television and print media) for community
education and fundraising purposes.
_______________________________ ______________________________
Signature of parent/guardian
Date
_______________________________ ______________________________
Signature of witness
Date
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
Healthy Waters Release of Information
Due to an increase in government regulations of swimming pool health and safety, Camp “Kids First”
is required to more actively prevent contaminations in recreational waters. This form is to help ensure
Camp “Kids First” uphold the highest standards of safety to protect the participants attending our
programs and the general public at the locations that host us during our off site activities. Fecal
contaminations are a very serious health risk to anyone in the pool and can lead to infection caused by
organisms that contaminate water in pools, lakes and hot tubs, resulting in diarrhea, skin rashes,
swimmer's ear, and other conditions. Camp “Kids First” is committed to eliminating our contribution to
this problem by collecting more in depth information about our campers and more specifically about our
campers who experience incontinence.
Incontinence is the inability to restrain natural discharges or evacuations of urine or feces.
Please check the box if your child:
 Requires supportive undergarments (ex. Diapers)
 Has toileting accidents not related to illness
 Has Irritable Bowel Syndrome or other conditions that may cause diarrhea
 None of the above
This information will be added to your child’s profile and it may require them to utilize a swimming
undergarment in order for them to safely enter the pool. Please sign and return this form with the rest
of the waivers in the Camp “Kids First” package. Your camper will not be able to participate in
swimming until this form has been completed and returned to Camp “Kids First”
Participant’s name:____________ _____________________________
Parent/Guardian signature:___________________________________
Date:____________________________________________________
Thank you very much for your help in making sure swimming is fun and safe for everyone!
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Camp “Kids First”
PARTICIPANT INFORMATION FORM
Personal Information
Collection
We collect personal information to assist us in planning and implementing safe and quality
programs.
Disclosure
This information will only be disclosed to Camp “Kids First” in partnership with McMan Youth
Services personnel or necessary personnel of programming partners. Names may be used in
promotional documents of the Camp “Kids First”, only when express permission has been
granted. Information will be disclosed to other parties only when express written permission is
provided.
Disposal
At the end of each program session, all data provided to authorized personnel is shredded.
The information gathered by the agency will be kept no less than 2 years, and may be kept
longer, after which time it will be disposed of by shredding to ensure confidentiality is
maintained.
Camp “Kids First” Registration
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