PineTree
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DI SCOVERING
A B I L IT I E S
TOGE THER
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Dear Parents and Guardians:
Thank you for your interest in having your child attend Camp Pine Cone in 2012. Many of last year's
summer staff members will be returning and are looking forward to another safe, enjoyable and
memorable season on North Pond. Your application for the 2012 season is enclosed. Please read
the below information carefully.
Important notes about the application packet
The enclosed application packet includes:
•
Four-page Camper Application
• Two-page Health History
• Child Camper Eligibility
•
Return envelope
P.O. Box 518
149 Front St.
Bath. ME
04530
All forms and the $25.00 registration fee must be completed and returned to us in order to
start the enrollment process.
71U.S. Roule I
Changes in the summer schedule
Camp Pine Cone will be running only two weeks . These sessions will run consecut ively with the Pine
Tree Camp children's sessions four and five.
Suite B
Scarborough. ME
04074
Camper enrollment
Campers are enrolled on a first-come, first-served basis. A total of 15 camper slots per session will
be available in 2012. Session assignments for applicants will be made at my discret ion, in
consultation with parents and other concerned parties. My goal is to schedule campers into the
sessions that are most appropriate and enjoyable for them.
114 Pine Tre e Rd.
Rome. ME
04963
207.443.334 1
Application process questions and additional details
If I should need additional information to process the application , I will contact you at the telephone
number/s you provide. All applicants will receive a follow-up letter indicating that they have been
accepted or have been placed on a waiting list (if the application is processed/ received after all
available slots have been filled).
Should your child be accepted to camp , we will need your primary care physician/family physician to
conduct a physical exam of the applicant and complete the Physical Examination form . (Please note:
Campers will receive this form with their acceptance letter, it is not included in this mailing.)
If you have any quest ions or concerns , please contact me at the telephone numbers or e-mail
address listed on the application . In closing , I wish you all the best in the year ahead.
Sincerely ,
Dawn Willard -Robinson
Director
Pine Tree Camp
W I\' W .
p i n e I r e c
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For office use only
Date Received ___________
Session # ______________
Deposit Received ________
Check Number __________
Accpt. Ltr _______________
A program of Pine Tree Society
2012 Camper Application
Please print or type
Camper Information
Camper name ______________________________________________________________________________
Last
First
Initial
Address ___________________________________________________________________________________
Street
City
Phone Number _________________________
State
Zip
DD
Year
Date of Birth
MM
E-mail ____________________________________________________________________________________
Family Information
Parent’s Name ___________________________________
Phone Number __________________________
Address ___________________________________________________________________________________
If different from above
Place of Employment ______________________________
Phone Number __________________________
Parent’s Name __________________________________
Phone Number __________________________
Address ___________________________________________________________________________________
If different from above
Place of Employment ______________________________
Phone Number __________________________
Guardian’s Name ________________________________
Phone Number __________________________
Address ___________________________________________________________________________________
If different from above
Place of Employment ______________________________
Phone Number __________________________
Emergency Contact Information
1. Name _______________________________________
Phone Number __________________________
Relationship to camper _______________________________________________________________________
2. Name _______________________________________
Phone Number __________________________
Relationship to camper _______________________________________________________________________
Camper Information
Camper’s disability (please be specific)
Educational History (Please note grades completed and schools attended)
Camper attitude about camp
Parent attitude about camp
Has camper attended camp before ( Y / N ) When and where
Camper Health Questions
Movement:
Walks on their own
Walks with braces
Uses walker
Uses cane
Uses wheelchair
Chair is electric
Can drive electric chair ( Y / N )
Chair is manual
Can push manual chair ( Y / N )
camper can get in and out of chair without help ( Y / N )
Personal Care:
Dresses self ( Y / N )
Feeds self ( Y / N )
Bathes self ( Y / N )
Will require one-on-one care/supervision ( Y / N )
Toileting:
Does camper have bladder control ( Y / N ) Bowel control ( Y / N )
Use catheter ( Y / N )
Self cath ( Y / N )
Wears Depends ( Y / N )
Ileo bag ( Y / N )
Wet the bed ( Y / N )
Does camper have bowel regime ( Y / N )
Personal grooming ( Y / N )
Communication:
Speech or language problem ( Y / N )
Visual impairment ( Y / N )
Seizures:
Have seizures ( Y / N )
Hearing problem ( Y / N ) Hearing aid ( Y / N )
Uses glasses or contact lenses ( Y / N )
Type ( Grand Mal / Petite Mal )
Date of last seizure _______________________________________________________
Please note: Camper must be on a stable seizure medication regime and not in the process of changing medication or
altering the dosage of current medication for at least one month prior to camp.
General:
Food Allergies ( Y / N )
Allergies to insects, animals, plants ( Y / N )
Medicine Allergies ( Y / N )
Special Diet ( Y / N )
Current Immunizations ( Y / N )
Current Tetanus shot (date) __________________
Any activities camper cannot take part in ( Y / N )
Have a shunt ( Y / N )
Recent illnesses, surgery or hospitalization ( Y / N )
History of behavioral problems ( Y / N )
Taking medication for depression ( Y / N ) Recent family loss or other cause for depression ( Y / N )
Please explain any “Yes” answers from above ____________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
How did you hear about Camp Pine Cone? _______________________________________________________
Camper Tee Shirt Size:
Person completing this application
Name ______________________________________
Signature _____________________________________
Relationship to camper _______________________________________________________________________
Address ___________________________________________________________________________________
Phone number _______________________________
E-mail _______________________________________
Please note: the applications are accepted on a first-come, first-served basis.
Release Information (please initial and sign)
Date ______________________________________________
__________
I hereby certify that I am the parent/guardian of the above named camper. I consent to the
participation of the camper in all normal camp activities which the staff believe to be appropriate for his/her
physical condition. I further consent to allow the camp staff, operating under the camp nurse, administering to the
camper those regular medication which have been prescribed for the camper. In case of medical emergency, I
understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give
permission to the medical personnel selected by the Camp Director to order X-Rays, routine tests, treatment and
other emergency care necessary; to release any records for insurance purposes; and to provide or arrange
necessary related transportation for the named camper.
__________
I hereby affirm that I am the parent/guardian of the above named camper and I hereby give my
consent that photographs, videos, and/or stories of his/her or any reproduction of same, may be used by the Pine
Tree Society, or by others with the consent of the Pine Tree Society, for the purposed of illustration or publication
in any manner.
Name ______________________________________
Signature _____________________________________
Relationship to camper _______________________________________________________________________
Camper session assignments will be at
the discretion of the camp director in
consultation with parents, campers,
and other concerned parties.
Your acceptance letter will indicate which
session you will be invited to attend.
2011 Summer Schedule
Session 8: July 16 to 20, 2012
Session 9: July 23 to 27, 2012
Pine Tree Camp
(before May 15)
P.O. Box 518, Bath, ME 04530
phone 207-443-3341 fax 207-443-1070
[email protected]
(after May 15)
114 Pine Tree Camp Rd, Rome, ME 04963
phone 207-397-2141 fax 207-397-5324
[email protected]
Financial Information
The actual cost per camper attending Camp Pine Cone is $150.00 per 5-day session. The fee includes all
activities, a T-shirt and snacks. Campers are to bring bag lunches. Each session will close with a family social.
Please note: A $25.00 registration fee is required to reserve enrollment at Camp Pine Cone.
Payment Information: For your convenience, Camp Pine Cone payments may be made securely on-line using a
credit card. Simply visit www.pinetreesociety.org/cpc.asp and click “Pay Tuition Online.” You may also send
payments to: Pine Tree Society, P.O. Box 518, Bath, ME 04530.
Funding Source
If the camper is eligible for respite or other funding for state, civic, religious or private agencies, please apply to
these agencies and let us know the following information.
Contact name ______________________________________________________________________________
Title _______________________________________
Agency ______________________________________
Address ___________________________________________________________________________________
Phone _____________________________________
Amount requested ______________________________
Anticipated date when you will hear back from them _________________________________________________
Please return this application to Pine Tree Camp Director:
Before May 15
P.O. Box 518
Bath, ME 04530
207-443-3341
After May 15
114 Pine Tree Camp Road
Rome, ME 04963
207-397-2141
Before May 15
PO Box 518 Bath, ME 04530
phone 207-443-3341 fax 207-443-1070
After May 15
114 Pine Tree Camp Rd, Rome, ME 04963
phone 207-397-2141 fax 207-397-5324
A program of Pine Tree Society
Camper Health History Form Part 1
This form to be completed by parent or guardian
Camper’s Name ____________________________________________________
Sex _______________
Birth date __________________________________________________________
Age _______________
Home Address _____________________________________________________________________________
Phone Number ___________________
Emergency Contact Information
Custodial Parent/Guardian ________________________________
Phone Number ___________________
Address __________________________________________________________________________________
Business Address ________________________________________
Phone Number ____________________
Second Parent/Guardian/Emergency Contact ________________
Phone Number ____________________
Address ___________________________________________________________________________________
Business Address _______________________________________
Phone Number ____________________
If not available notify ___________________________________
Phone Number ____________________
Address __________________________________________________________________________________
Business Address ________________________________________
Phone Number ____________________
Medical Insurance Information
Is the participant covered by family medical/hospital insurance? ( Y / N )
If yes, Carrier of Plan name __________________________________
Group # _______________________
Carrier Address ____________________________________________________________________________
Name of Insured _____________________________________
Relationship to participant ______________
Is the plan a Managed Care Program? ( Y / N )
If yes, Carrier or Plan Name ___________________________
Group # _____________________________
Name of Primary Care Physician __________________________
Phone Number ____________________
Address ________________________________________________________________________________
Medicaid/Medicare Information Since Maine Medicaid is now managed care, it is imperative that the following
information be provided as accurately as possible.
__________
I participate in a Managed Care Program for my Medicaid
__________
I do not participate in a Managed Care Program for my Medicaid
Name of Managed Care Carrier _______________________
Phone Number __________________________
Carrier Address _____________________________________________________________________________
Policy/ID # _______________________________________
Group # ________________________________
** Medicaid/Medicare # _____________________________
Primary Care Physician ___________________
Address ____________________________________________________
** A current Medicaid/Medicare card must be presented during registration
Phone Number ______________
Health History Form Part 2
Specific Disability ______________________________ Secondary Disability ____________________________
General
Which of the following has the camper had? Check and give the appropriate dates.
______ Measles
______ German Measles
______ Chicken Pox
______ Mumps
______ Hepatitis
______ Varicella Zoster
______ Convulsions
______ Diabetes
______ Frequent Ear
______ Mononucleosis
______ Bleeding/Clotting
Infections
Disorders
Allergies/Diet
Medication (Please be specific) _________________________________________________________________
Food Allergy (Please be specific) _______________________________________________________________
Dietary Modification __________________________________________________________________________
__________________________________________________________________________________________
Seizures
Does camper have seizure? ( Y / N )
Under control with medication ( Y / N )
What type of seizure ___________________________
How often ___________________________________
Duration of seizure ____________________________
Date of last seizure ____________________________
Please note: Camper must be on a stable medication regime. He/she should not be in the process of changing or
altering the dosage of medication for at least a month.
Activities
Activities to be restricted (Please list) ____________________________________________________________
__________________________________________________________________________________________
Activities to be encouraged (Please list) __________________________________________________________
__________________________________________________________________________________________
This health history is correct and complete as far as I
know and the person herein described has permission to
engage in all camp activities except as noted.
Signed ____________________________________________________________________________________
Parent/Guardian Authorization
Printed Name _______________________________________________________________________________
Date ______________________________________________________________________________________
Please note: If an outbreak occurs, the state health services will immunize the camper without your permission if
the immunization history is not complete.
Camp Pine Cone Child Camper Eligibility Policy
Please read and return this form with the camper’s completed application.
To be eligible to attend a session at Camp Pine Cone, a program of Pine Tree Camp, a child must meet
all of the following requirements:
The child must:
•
Be between of 5 and 12 years of age.
•
Have a diagnosis of physical or developmental disability.
•
Be able to interact with others, be cognitively aware that he/she is participating in a camp
program, be able to be involved in activities with other campers and respond to staff.
•
Be able to adapt to the group living environment of camp without disrupting others during
sleeping hours, meals and program activities.
•
Be free of inappropriate sexual behavior.
•
Be able to adapt to a staff supervision ratio of 1 staff to 3 campers. We are prepared to provide
One-on-One care when needed for feeding, bathing, toileting, etc., but WE DO NOT HAVE THE
RESOURCES TO SERVE CHILDREN WHO REQUIRE CONSTANT ONE-ON-ONE CARE
THROUGHOUT THE DAY.
•
Be free of emotional outbursts and capable of being able to restrain himself/herself at all times.
WE CANNOT ACCEPT A CHILD WHOSE BEHAVIOR MAY REPRESENT A DANGER TO
HIMSELF/HERSELF OR OTHERS.
•
Be toilet trained, unless there is a valid medical reason for incontinence. We are prepared to
assist campers who have limited bowel and bladder control due to their medical condition/s and
are also prepared to deal with occasional accidents. WE ARE UNABLE, HOWEVER, TO
ACCEPT CAMPERS WHO ARE SIMPLY NOT TOILET TRAINED AND ARE UNABLE TO
ASK FOR HELP BEFORE SOILING THEMSELVES.
•
Be free of medical conditions that, in the opinion of our medical staff, may represent a danger to
himself/herself or others. Each applicant will be judged on an individual basis, but as a general
rule, A CHILD IS NOT CONSIDERED A CANDIDATE FOR CAMP IF HE/SHE IS JUDGED TO
HAVE A MEDICAL CONDITION ASSOCIATED WITH A HIGH RISK FOR COMPLICATION
OR INJURY TO HIMSELF/HERSELF OR OTHERS.
•
Be on a stable seizure medication regime and not in the process of changing medication or
altering the dose of current medication for at least one month prior to arriving at camp.
I meet the above criteria Yes _____
No _____
Name of camper: ________________________________________
Signature of parent/guardian ___________________________________ Date:_________