Youth Weekend Retreat 2015
Application Cover Letter
The Youth Weekend Retreat is designed to support independent experiences
for youth ages 16-18 (up to 21 if still in high school) and who have an acquired brain injury
and/or a physical disability.
The Youth Weekend Retreat will run Friday January 23rd at 5:00pm to Sunday
January 25th at 2:00pm, 2014 at YMCA Geneva Park. The Youth Weekend Retreat is a
partnership with March of Dimes Canada and Holland Bloorview Kids Rehabilitation Hospital.
What to expect:
 All meals and snacks will be provided (this includes dinner on Friday).
 Shared accommodation for 2 nights.
 Attendant care will be provided if needs are identified during the application process.
 Youth to take part in all workshops, recreation activities and social opportunities.
Please note: Space is limited. Not all applicants will be offered a spot. If a conditional
acceptance* is offered, consent forms must be signed, including a form that must be
completed by your doctor (*based on no change to your medical status).
Sessions:
The following topics will be offered:
 health and wellness
 relationships and friendships
 planning beyond school
 preparing for living away from home
Do you have another topic you would like addressed? Please share topics of interest:
______________________________________________________________________
______________________________________________________________________
Fees:
 The program fee is $350.00, payable in full (by cheque only) at the time of application.
 Applications received without payment will not be processed.
 Please make cheques payable to March of Dimes ABI Services
 Cheques can be postdated to December 8, 2014.
 Please write “Youth Weekend Retreat” in the memo line.
 Fees are non-refundable. Cancellation requests will be considered on an
individual basis. Refunds are granted at the discretion of March of Dimes Canada
and Holland Bloorview Kids Rehabilitation Hospital.
Please return all completed forms with payment to:
Robyn Persaud
Participation & Inclusion
150 Kilgour Road, Toronto ON
M4G 1R8
Phone: 416-425-6220 Ext. 3296
Fax: 416-422-7037
Youth Weekend Retreat
Application
Section A – General Applicant Information
Last Name:
Initial:
First Name:
Address (#, Street, Unit #):
City/Town:
Gender:
Male
Province:
Date of Birth (dd/mm/yy):
Postal Code:
Health Card Number:
Version Code:
Female
Home Telephone:
(
)
Cell Telephone:
(
)
Section B – Emergency Contact Information
Emergency Contact Name:
Relationship to Applicant:
Address:
City/Town:
Province:
Home Telephone:
(
)
Cell Telephone:
(
)
Other Telephone:
(
)
Other Telephone:
(
)
Postal Code:
Additional Emergency Contact Information
Emergency Contact Name:
Relationship to Applicant:
Address:
City/Town:
Province:
Home Telephone:
(
)
Cell Telephone:
(
)
Other Telephone:
(
)
Other Telephone:
(
)
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Section C – Diagnosis information:
Code (for office use only) :
Detailed description of injury and/or disability:
Year of Injury (if applicable):
Please describe if there is anything else we should be aware of (i.e. learning disability, vision impairment,
etc):
Please describe how your answer(s) above affect you physically (i.e. transfers, communication, etc) or
cognitively (i.e. processing information, etc) :
Section D – Medical Information
Do you experience seizures:
Yes
No
If yes, please list date of last seizure:
(dd/mm/yy)
Frequency:
Type of seizure (please describe):
Intervention/how they are managed:
If more than standard first aid is required (ex. Medication administration), please include a specific seizure
protocol from your Physician (form will be provided if required).
Do you have any allergies?
Yes
No
Please specify - food, environmental, substance, etc.
Intervention/how they are managed:
Are there any special considerations staff should be aware of? (i.e. do you have any practices specific to cultural beliefs;
do you experience pain/discomfort; are there any foods you have difficulty eating; do you have anxiety in crowds, environments etc.?)
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Section E – Medication
Do you take any medication?
Yes
No
Do you take your medication on your own?
Yes
No
(Please consider routine medication, emergency
medication and as needed medication such as
Tylenol or Gravol)
If no, please indicate the type of assistance required:
Remembering when to take
Remembering how much to take
Storing medication
Opening containers
Administering medication
Other:_____________________________________
If yes, please list below
Medication name:
Reason for use:
Dosage:
Strength:
Storage:
Time given:
Additional information:
Medication name:
Reason for use:
Dosage:
Strength:
Storage:
Time given:
Additional information:
Medication name:
Reason for use:
Dosage:
Strength:
Storage:
Time given:
Additional information:
Medication name:
Reason for use:
Dosage:
Strength:
Storage:
Time given:
Additional information:
Medication name:
Reason for use:
Dosage:
Strength:
Storage:
Time given:
Additional information:
Medication name:
Reason for use:
Dosage:
Strength:
Storage:
Time given:
Additional information:
*if not enough space, please attach additional sheets with additional information
NOTE: The Youth Weekend Retreat does not provide medical care such as dialysis treatments or insulin injections.
It is a life skills and recreation service that provides attendant care services if required. Participants must be able to
self-direct their own medication. If you have concerns, please speak with your lead staff.
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Section E – Assistive Devices
Do you use an assistive device?:
Yes
No
IF YES, which of the following do you use?:
Cane
Crutches
Walker
Braces/AFO’s
Manual Wheelchair
Electric Wheelchair
IF YOU USE A WHEELCHAIR, are you able to walk to some extent with assistance?:
Yes
No
Section F – Risk of falls
Is there a history of illness-related falls?
Yes
No
If yes, please explain:
Are there any strategies in place to prevent the
occurrence of falls?
Yes
No
If yes, please explain:
Section G – Activities of Daily Living and Personal Care Requirements
This section is very important in the planning of your care at the retreat.
Please make sure that you fully explain the how much assistance you require for each of the activities.
Task
Total Assistance
(75-100%)
Some Assistance
(25-75%)
No Assistance
(0-25%)
Eating
Additional information (if needed):
Brushing teeth
Washing hands/face
Grooming (shaving)
Dressing (upper body)
Additional information (if needed):
Dressing (lower body)
Additional information (if needed):
Showering / bathing
Additional information (if needed):
Toileting
Additional information (if needed):
Transferring: On & off the toilet
In & out of the bathtub
In & out of bed
In & out of a wheelchair
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Section G (continued) – Activities of Daily Living and Personal Care Requirements
IF YOU NEED ASSISTANCE WITH TRANSFERRING, what is your preferred method:
Hoyer
2-person transfer
1-person transfer
Additional information (if needed):
Do you require:
Turning at night?
A Hospital Bed?
Do you use a G-Tube?
Do you have
control of your:
Bowels
Bladder
Neither
Yes
Yes
Yes
Do you use:
Toilet
Commode chair
Bed pan/ urinal
No
No
No
IF YES, how many times?:
Night-time help
required?
Yes
Yes
Yes
No
No
No
Do you require:
Do you use:
Catheter irrigation
Disempaction
Enemas
Laxatives
Suppositories
Attends
Condom drainage
Colostomy
Ileoconduit
Catheter:
Type:
Section H – Communication
(a) Do you wear hearing aids?
(b) Do you have speech difficulties?
Yes
Yes
No
No
IF YES to (a) or (b) above, how do you communicate?:
Verbal
Bliss board, symbol or picture board
Sign language
Other (specify):
Section I – Social Development
Choose one of the following options below to describe your social interactions:
I have no difficulties being in social situations.
I may need support and encouragement when getting involved in new experiences.
I am not comfortable socially. I need a lot of assistance with social situations.
Which one best describes your decision-making skills?
Independent (no assistance necessary)
Need some prompting
Need total assistance
Which one best describes your ability to figure things out?
I can clearly understand directions and respond correctly.
Sometimes I need some direction and someone to explain more to me.
I am usually confused by simple tasks.
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Section J – Transportation
Transportation to and from the retreat is the responsibility of the participant.
If you do not have transportation please let us know.
It may be possible to arrange for transportation.
I require transportation:
To the program
From the program
Section K – Retreat Date and Program Fee
Retreat Date:
January 23, 2014 to January 25, 2015
Fee: $350 (CHEQUE ONLY- made out to “March of Dimes ABI Services”)
The program fee includes: accommodation and meals.
The full program fee must accompany this application form for the applicant to be considered for acceptance.
Section L: Verification and Signature
I verify that the information that has been given in this application is complete and accurate to the best of my
knowledge. I agree to abide by the rules of the retreat and to conduct myself in a socially appropriate manner, and I
understand that failure to so may result in my being asked to leave the retreat.
Date (dd/mm/yy):
Consumer/Substitute Decision Maker Signature:
Please return this form to the following:
Robyn Persaud
Holland Bloorview Kids Rehabilitation Hospital
Participation & Inclusion
150 Kilgour Rd.
Toronto, ON
M4G 1R8
Tel: (416) 425-6220 ext. 3296
Fax: 416-422-7037
Please note that submitting an application does not guarantee acceptance.
The deadline for applications is October 30, 2014.
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