South East Consortium Summer Day Camp Programs
Thank you for your interest in the South East Consortium Summer Day Camp Programs. I am delighted
to share with you the following information which provides a basic understanding of these unique and
highly respected inclusive summer day camp programs.
This year we will be offering SEC Summer Day Camps in the Town of Eastchester and Village of
Scarsdale. Based on the fact the highest percentage of campers comprising enrollment in 6th, 7th & 8th
grades reside in Eastchester, Bronxville and Tuckahoe, South East is partnering with the Town of
Eastchester Department of Recreation to enroll summer campers in the aforementioned grades in the
Eastchester Camp Galaxy which is located at Eastchester High School. This transformation will solve the
overcrowding in Scarsdale and will offer our Eastchester, Bronxville and Tuckahoe campers the
opportunity to attend camp in their own town.
If you decide your child meets our eligibility requirements and you wish to pursue registration, please
complete the registration packet and forward with payment as stated below. If you are new to South
East, you will be required to make an appointment with your child for a brief in-take appointment to
assess your child’s preparedness for camp and to finalize registration. If it’s decided your child will be
registering for camp, more comprehensive information will be provided. Please read the following
carefully, as the structure of camp has changed to accommodate the programs growth.
Orientation Meeting for Families: An orientation meeting for families will be held on Wednesday, June
14th at the Mamaroneck Town Center, Conference Room C from 6:30-8:30PM. It is highly
recommended all families attend. It is mandatory for any new families to attend.
Camp Dates: Camp will run from July 3rd to August 4th, No Camp Tuesday, July 4th in observance of
Independence Day (24 days) between the hours of 9:00AM to 3:00PM for SEC Scarsdale Day Camp and
July 5th – August 4th for SEC Eastchester Day Camp (23 days) between the hours of 9:00AM – 3:30PM.
Camp Location and Age/Grade Levels: These unique inclusive camp program’s run in cooperation with
the Village of Scarsdale municipal camp which operates at 4 different locations (schools) based on age
and school grade level. South East operates camp at 3 of the 4 locations. In addition, the Town of
Eastchester will be hosting camp for 6th – 8th graders at Camp Galaxy who reside within Eastchester,
Tuckahoe and Bronxville. All campers enrolled with South East are interactively grouped with municipal
campers as appropriate. South East campers are supervised by South East staff that will be accountable
to a South East Camp Director at each camp location.
Camp Lenape (1st Grade): Fox Meadow Elementary School
Camp Wapetuck (2nd Grade): Quaker Ridge Elementary School
Camp Patthunke (3rd-8th Grades): Scarsdale Middle School for campers residing in Scarsdale,
Mamaroneck, Larchmont, Harrison, Rye, Pelham and Portchester.
Camp Galaxy (6th-8th Grades): Eastchester High School for Campers residing in Eastchester, Tuckahoe and
Bronxville. (Please see separate registration packet)
Camper Eligibility: Any child, age 5 to 14 who is diagnosed with a Developmental Disability (ask for a
definition) who resides in one of the component municipalities and is confirmed OPWDD eligible for
reimbursement under the New York State Office for People with Developmental Disabilities Office
guidelines will be given priority. Children with other special needs or those who do not qualify for
OPWDD Eligibility are encouraged to seek registration but will need to pay an additional fee. Children
utilizing wheelchairs who are capable of transference are also encouraged to seek registration.
However, it must be understood that South East, due to staffing limitations, cannot accept any child
requiring specialized health care or supervision which exceeds the ability of South East to properly
accommodate. Also, South East cannot accept for enrollment children who present severe behavioral
challenges and are deemed inappropriate for such a camp environment.
If there is a camper age 5 who is entering Kindergarten and resides in the Village of Scarsdale we will
discuss with you the possibility of that child attending Camp Sagamore. Other campers age 5 will be
required to attend Camp Lenape (1st grade) due to funding limitations.
Camp Cost:
Confirmed OPWDD Eligible/HCB Medicaid Wavier $525.00
Non-OPWDD Eligible/Other $925.00
The average cost incurred by South East for your child to attend summer camp is approximately
$1,850.00. Interpretation of Medicaid Waiver regulations permits SEC to assess families a cost of
$525.00 based on allowable expenses. Campers who are Non-OPWDD Eligible/Other are assed a fee of
$925.00.
Round-Trip Transportation Cost: $450.00
Round-trip transportation is available to all campers residing in component municipalities at a cost
$450.00. Centralized pick-up/drop-off locations will be determined after the camp registration deadline.
Bus drivers are professional drivers. Each bus has a monitor for safety purposes. Our ability to transport
is limited, so please act accordingly.
Registration: Registration is open to members of the consortium through May 22nd, 2017. If space is
available registration will be open to members outside the consortium after 5/22/17. Please note we
have a limited number of spots available at each camp site this year. 6th – 8th grade camp site
registration is determined by the municipality to which you pay your taxes, not by school district or
mailing address. Please fill out the corresponding forms for the camp your will be attending.
Payment: Full payment for camp would be appreciated at the time of enrollment/acceptance. A
payment plan for camp requires $100 deposit due at the time of enrollment/acceptance and the second
payment by May 8th, and the final payment on June 19th. Full payment must be received by June 19th for
your child to attend camp.
Camp Staff: South East employs a seasoned, experienced professional as Camp Director at each camp
site. South East provides counselor staff at a 1:2 ratio to supervise campers at all times. If it is mutually
agreed your camper requires 1:1 supervision, then we will discuss with you an additional cost to cover
that additional expense. Camp counselors range from teacher aides, to college and high school
students. All staff realize their primary function is to provide productive, enjoyable camp activities for
campers in a respectful and safe manner. South East shares the services of an EMT personnel for health
purposes. Each staff must undergo a criminal background check and fingerprint screening. All staff
attend a three-day orientation session prior to the start of camp.
South East Consortium for Special Services, Inc
740 W. Boston Post Road, Ste 316
Mamaroneck, NY 10543
Telephone: (914) 698-5232
www.secrec.org
South East Consortium
Summer Day Camp at Scarsdale Registration Form 2017
It is imperative that all requested information below is provided. There will be no exceptions. Failure to provide the requested
information may result in your child not being accepted. Registration open to Consortium registrants through 5/22/17. (Registration
will open to campers outside the consortium area if space is available after the above date only.) Each camper must have a current
South East Admission Application and SEC Medical form on file (which is valid for 3 years). In addition, updated immunization
record needs to be attached to this registration form. *Note: 6th – 8th grade camp site registration is determined by the municipality to
which you pay your taxes, not by school district or mailing address.
Name of Camper: _____________________________________________________________________________
Address: ____________________________________________________________________________________
Municipality you pay taxes to: ___________________________________________________________________
Camper Information:
Date of Birth: __/___/_____ SS # mandatory: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Gender: ____________
Primary Diagnosis: _________________________________Secondary Diagnosis: _________________________
Is your child on Medicaid Waiver? _________________ If so, what is the CIN ? ___________________________
Parent/Guardian: _______________________________________________________________________________
Home Phone: ________________________________ Cell Phone: ________________________________________
Email Address: ________________________________ Emergency Contact: _______________________________
 My Camper will be attending ALL 5 weeks of camp.
My Camper will be away from camp on _________________________
What Camp Are You Requesting?
Camp Lenape (1st Grade: age 5-7) Camp Wapetuck (2nd Grade: age 7-8) Camp Patthunke (3rd – 8th Grade)
Summer Camp Confirmed OPWDD Eligible/HCB Medicaid Wavier $525.00
Summer Camp Non-OPWDD Eligible/and other $925.00
Round-Trip Transportation (available to campers inside the consortium area from a central pick-up location TBD) Fee: $450.00
Contact Jennifer Spenner-Kind for additional information.
A minimum Deposit of $100.00 is due with registration form to hold a spot for your camper.
TOTAL$__________________
Payment for camp must be made by June 19th, 2017.
PAYMENT PLAN: Payment plan for camp requires a deposit of $100 due with application, seconded payment by May 8th and final
payment on June 19th.
If you agree to the term of this agreement, please sign and date.
Signature__________________________________________________________________Date__________________________
FOR OFFICE USE ONLY
Date Registration Received: _______________ Date Medical Received _____________Payment made by: _________/____________
Date(s) Payment(s) Received: __________/___________ Check(s) #: ________ / _________ Amount(s): __________/ __________

JSK DP MB Medical Immunization Records IEP Application Sunscreen Swim
SCARSDALE DAY CAMP
OFF-SITE PERMISSION SLIP
The New York State Department of Health requires all camps to have written permission for children to
participate in any off site camp activities such as swimming at the Scarsdale Municipal pool, trips to the
Scarsdale Historical Society and/or the Weinberg Nature Center.
Please complete the form below and return it to the South East Consortium by June 19, 2017. Children
with signed permission slips will only be allowed to participate in the aforementioned activities. If you have
more than one child participating in camp, please fill out one form per child. PLEASE NOTE: All campers
visit the Scarsdale Municipal Pool daily, however not all camps go to the Scarsdale Historical Society or
the Weinberg Nature Center. Thank you for your assistance.
South East Consortium Day Camp Off-Site Activity
Permission Slip
I give my child
entering Grade (in September)
permission to participate in the Scarsdale Recreation Day Camp Off-Site Activity Program
conducted at the Scarsdale Municipal Pool Complex, Weinberg Nature Center and Scarsdale
Historical Society throughout the summer of 2017. I understand the following:
•
•
•
,
Campers will be transported to the off-site facilities by school bus.
Campers will be supervised by camp staff as well as qualified lifeguards at the swim facility.
Campers will be identified by their swim ability with a colored wristband.
Signature of Parent/Guardian:
Print Name of Parent/Guardian:
Please return by June 19, 2017 to:
South East Consortium For Special Services Inc.
740 West Boston Post Road, Suite 316
Mamaroneck, New York 10543
Fax number (914) 698-7125
South East Consortium for Special Services, Inc.
740 West Boston Post Road, Suite 316 | Mamaroneck, NY 10543
Program Admission Application
Please complete this application accurately and completely to ensure safety and program effectiveness
This application is valid for three years
Name of Participant: __________________________________________________________ DOB: _____/____/______ Sex: M F (circle one)
Participant’s Social Security # (required): _________________________ Participant’s Medicaid Waiver # (if applicable): ____________________
Parent/Guardian’s Name: _________________________________________________________________________________________________
Address: _______________________________________________________, ________________________________, _______, ______________
Street
Municipality
State
Zip Code
Home Phone: _____________________________ Cell Phone: _______________________________ Email: _______________________________
Emergency Contacts: (if parent(s)/guardian(s) are unavailable:
Primary Person: _____________________________________________________ Best Phone #: _______________________________________
Secondary Person: __________________________________________________ Best Phone #: _______________________________________
Relationship to Participant: Primary_____________________________________ Secondary _________________________________________
Parent/Guardian’s Release Statement
I am the parent/guardian of _____________________________________________ (Participant) on whose behalf I have submitted this
Admission Application for his/her participation in the programs and activities of the South East Consortium (SEC). I represent and warrant that,
to the best of my knowledge and belief, the Participant is physically and mentally able to participate in SEC’s programs and activities.
The SEC has my permission to use (both during and after a program or activity) the likeness, name, voice or words of the Participant in television,
radio, film, newspaper, magazine and other media or formats, for the purpose of advertising or communicating about the SEC’s programs and
activities and/or for the purpose of applying for or raising funds to support these programs and activities.
I hereby release and discharge the SEC, and its officers, directors, employees, supervisors and volunteers from any and all claims for damage,
personal injury and other liability in connection with events occurring while the Participant is involved in the SEC’s programs and activities.
If, during the Participant’s involvement in the SEC’s programs and activities, he/she were to need emergency medical treatment, I hereby
authorize the SEC to take such measures as it may deem necessary for the benefit of the Participant’s health and well-being (including, if
necessary, hospitalization).
Do you carry health/medical insurance for the Participant? Yes No. If “No” – I will be responsible for payment of all medical services rendered.
Name of Insurance Company: ____________________________________________________ Policy #: _______________________________
_____________________________________________________________________________________________________________________
Release of Test Score Information Required by New York State OPWDD
In order to ensure the Participant’s eligibility to receive the important funding which is provided to the SEC by the New York State
Office for People with Developmental Disabilities (OPWDD), the SEC is required to provide to said Office the individual I.Q. scores,
Vineland Adaptive Behavior Scale Scores or other recognized assessment instruments in connection with the Participant. By submitting
this application to SEC, you are confirming that the SEC may release this required information to the New York State OPWDD. Your cooperation is
appreciated.
Program Admission Application 02/2013
Delivery of the Participant
The South East Consortium may release the Participant only to the persons named below:
Name: ____________________________________________________________
Relationship: ________________________________
Name: ____________________________________________________________
Relationship: ________________________________
I give my permission for the Participant to arrive and depart the SEC’s programs on his/her own. Y N . Circle one
Signature: _________________________________________________________
Date: ______________________________________
Parent/Guardian and also by the Participant (if 18 years or older). Must be signed to participate.
Participant Information
Participant’s School or Workplace: ________________________________________________________________________________________
Brief description of family and living situation: ______________________________________________________________________________
____________________________________________________________________________________________________________________
What does the Participant enjoy during free time? ___________________________________________________________________________
____________________________________________________________________________________________________________________
What outcomes would you like the Participant to achieve? ____________________________________________________________________
____________________________________________________________________________________________________________________
Daily Living Activities
Comments___________________________________________
Assistance eating/drinking
 Yes  No________________________________________________________________________
Assistance with toileting
 Yes  No
____________________________________________________________
Assistance with dressing
 Yes  No________________________________________________________________________
Other thinks we should know____________________________________________________________________________________________
Social Ability_________________________________________________________________________________________________________
Interacts with others
 Yes  No________________________________________________________________________
Unusual fears or concerns
 Yes  No________________________________________________________________________
Aggressive behavior/outbursts
 Yes  No________________________________________________________________________
Leaves or wanders from groups
 Yes  No________________________________________________________________________
Other things we should know
 Yes  No________________________________________________________________________
Cognitive/Communication Ability________________________________________________________________________________________
Verbal/Non-verbal
 Yes  No________________________________________________________________________
Hearing speech/hearing impairments  Yes  No________________________________________________________________________
Other things we should know____________________________________________________________________________________________
Physical Ability_______________________________________________________________________________________________________
Ambulatory
 Yes  No________________________________________________________________________
Gross/fine motor ability
 Yes ______________________________________________________________________________
 No_____________________________________________________________________________________________________________
Over/under active
 Yes  No________________________________________________________________________
Likes physical activity
 Yes  No________________________________________________________________________
Other things we should know
Program Admission Application 02/2013
MEDICAL INFORMATION
This medical will be valid for three years from the date issued by the physician.
THIS SECTION IS TO BE COMPLETED BY A PHYSICIAN ONLY!!
Please return to: South East Consortium
PARENT/GUARDIAN IS
740 W. Boston Post Road, Suite 301
RESPONSIBLE FOR UPDATING
Mamaroneck, New York 10543
MEDICAL INFORMATION ON A
Telephone (914) 698-5232
REGULAR BASIS. Participants cannot attend programs
Fax (914) 698-7125
without an updated medical.
Name:__________________________________,
_______________________________________, ________________________________________
Last Name
First Name
Primary Diagnosis:____________________________________
Down Syndrome
Yes
HISTORY OF…
(include comments at right for “YES” responses)
CHECK ONE
Allergies (Food, Bee Stings, Etc.)
Anxiety
Asthma
Bladder/Kidney Problems or Loss of Function in one
Kidney
Bleeding Problem
Bone or Joint Problem
Bruising
Circulatory Problems
Contact Lens/Glasses
Depression
Diabetes
Emotional Problems
Fainting Spells
Head Injury/History of Concussion
Hearing Aid/Hearing Problems
Heart Problems
Heart Illness
Hernia or Absence of one Testicle
Hepatitis
TYPE:____________
Hypoglycemia or Hyperglycemia
Motor impairment Requiring Special Equip.
(i.e., Wheelchair, Orthopedic Device)
Recent Contagious Disease
Seizures: Date of Onset: _____/_____/_____
Type:
Special Diet Needs
Vision Problems and/or vision less than
20/200 in One or Both Eyes
Other
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
No
Update 2/28/2006
Atlanto-Axial Instability by X-Ray Evaluation Results
Date:________ Positive Negative No X-Ray Given
COMMENTS/OTHER RESTRICTIONS
HISTORY OF DISEASE(S):
Chicken Pox
Mumps
Measles
Pneumonia
German Measles
Rheumatic Fever
Tuberculosis
Middle Name
Secondary Diagnosis:_____________________________________________
Blood Pressure ___________/_________
Frequency:
Time of Day:
DATE OF ONSET:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Duration:
MEDICAL HISTORY
IMMUNIZATION RECORD
(Required By NY State Law)
Any participant born before 1/1/57 does not have to complete the immunization record # 3 – 6
Diptheria/Tetnus Toxoid (4 doses) dates:
1)
2)
3)
4)
1)
1)
1)
1)
2)
2)
2)
2)
3)
3)
3)
3)
4)
4)
4)
4)
(must be boostered every 10 years)
Hepatitis B Vaccine (3 doses):
Oral PolioVaccine (3 or more doses) dates:
Live Measles Vaccine (2 doses) dates:
Live Rubella Vaccine (1 doses) date:
Live Mumps Vaccine (1 dose) date:
Haempphilus Influenza type B (Hib) (1 dose) date:
Varicella (chicken pox) (1 dose) date:
Give Dates:
_________________
_________________
_________________
Results of:
TUBERCULIN TEST_______________________
CHEST X-RAY:____________________________
TETANUS:________________________________
MEDICATION INFORMATION: MUST BE FILLED OUT COMPLETELY, EVEN IF PARTICIPANT DOES NOT TAKE
MEDICATION AT PROGRAMS. (Please Initial in the box provided if adult (age 18 or over) participant may self-administer
medication during program hours). Please contact SEC office for medication self-administration form.
Medication
Initial
ALLERGIES TO MEDICATION:
Purpose
YES
Dosage
Frequency
Time
NO
If yes, What?______________________________________________
______________________________________________
If there is a change in any of this information, a new form must be completed.
MEDICAL RELEASE
South East Consortium provides community-based recreation for individuals with disabilities, with an emphasis on physical activities.
If you feel any particular activity is contra-indicated for this individual, PLEASE CHECK ONLY THOSE ACTIVITIES IN WHICH
THE PARTICIPANT MAY NOT PARTICIPATE.
Alpine Skiing
Basketball
Bowling
Cycling
Dance
Diving
Equestrian
Figure Skating
Fitness/Aerobics
Floor Hockey
Golf
Gymnastics
Motor Activities
Nordic Skiing
Roller Skating
Soccer
Softball
Strength Training
Swimming
Tennis
Track & Field
Volleyball
Other
I, the undersigned have reviewed the above medical history and certify there is no medical evidence available to me which would
preclude his/her participation in South East Consortium for Special Services Recreation Programs.
Doctor’s Name: (Printed)_________________________________________________________________________________
Doctor’s Signature (must be signed in ink)____________________________________________________________________
Address:________________________________________________________________________________________________
___________________________________________________________________________________________Zip:_________
Telephone:
(
)__________________________________________________________Date:_____________________
Fax:: (
)____________________________________ E-Mail:_____________________________________________
Update 2/28/2006