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Chatter Camp Application
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Chatter Camp Application
Chatter Camp Application
Chatter Camp Contact:
Beth Warren
Phone:
423-298-8991
Email:
Beth_Warren@SignalCenters.org
Please check which date(s) you are applying for:
June 7-11
Participant Info
First Name
Last Name
Preferred Name
Sex
Male
Female
Ethnicity
---
Asian
Black
Hispanic
White
Other
Date of Birth
Age
Grade
School Attended
Teacher's Name and Phone Number
Teacher's Email
Do you give permission for Camp Signal Staff to discuss your child’s needs/interests with current teacher?
Yes
No
(Parent's Initials)
At school, does your child require a one-on-one assistant?
Yes
No
Participant's T-shirt Size
YS
YM
YLS
M
L
XL
XXL
XXXL
Weight
Height
Parent/Guardian Info
Mother
Mother First Name
Mother Last Name
Address
Primary Phone
Phone Type
Cell
Home
Work
Secondary Phone
Phone Type
Cell
Home
Work
Do you live in the Chattanooga city limits?
Yes
No
Email
Employer
Father
Father First Name
Father Last Name
Address
Primary Phone
Phone Type
Cell
Home
Work
Secondary Phone
Phone Type
Cell
Home
Work
Do you live in the Chattanooga city limits?
Yes
No
Email
Employer
Emergency Info
First Contact Name
Relationship
Primary Phone
Secondary Phone
Authorized to pick up?
Yes
No
Parent's Initials
Second Contact Name
Relationship
Primary Phone
Secondary Phone
Authorized to pick up?
Yes
No
Parent's Initials
Does the Participant?
Have a behavior plan? (If Yes, please provide a copy.)
Yes
No
Parent’s Initials
Run away or is he/she a “runner”?
Yes
No
If yes, are there triggers?
Exhibit self-injurious behaviors?
Yes
No
If yes, please describe those behaviors
Wear glasses/contact lenses?
Yes
No
Use a wheelchair?
Yes
No
Crutches?
Yes
No
Walker?
Yes
No
Is the participant verbal?
Yes
No
Use a communication device?
Yes
No
If so, please list what system or app is being used?
Have emotional upsets?
Yes
No
Sometimes
If yes, what usually triggers emotional upsets?
What normally calms down the participant, if he/she becomes upset?
What are identified rewards or motivators for your child?
Does he/she have trouble communicating wants and needs?
Yes
No
Limited Speech
Health
Does the participant have allergic reactions, including allergies to food or environmental?
Yes
No
If yes, what are those reactions and the protocol?
Please list ALL oral medications the participant takes, including OTC medicines. Bring all oral medications to camp in original containers with the participant’s name, dosage, and administration times. Medications must be given to the Camp Nurse or Staff by a parent or guardian.
DO NOT ALLOW CHILDREN TO BRING MEDICATIONS.
Attach additional paper, if necessary. Please make every effort to administer medications to your child prior to daily arrival at camp.
Medication Name
Total Dosage per Administration
Total # of Pills per Administration
Special Instructions
Specific Times to Administer (ex. 9am, 2:30pm, etc.)
To be Given During Camp Hours?
---
Yes
No
---
Yes
No
---
Yes
No
---
Yes
No
Is there is any medical information the nurse needs to know about your child that is not listed on the application or in the health checklist
(requires tube feedings, asthma that is typically exercised induced, has a g tube that is not being used, requires thick it for swallowing liquids, etc.)?
Yes
No
If yes, please describe in detail. Use and additional sheet if necessary:
Typical camp activities include dancing, sports, games, cooking, arts and crafts, playground activities, water days and more. Please describe or attach any instructions or precautions that should be taken during routine camp activities.
Please list any camp activities in which the participant may NOT participate.
It is agreed that Signal Centers assumes no responsibility for the participant’s personal property and is released from liability in connection with camping activities and medication administration, except as covered by the participant’s insurance. I understand my participant will be outside participating in various recreational activities.
Parent/Guardian's Printed Name
Date
Parent/Guardian Signature: (to be signed at open house)
Release Form
Permission is hereby granted for official representatives of Signal Centers and the business or individuals it designates to photograph my child, while participating in the 2021 Camps at Signal Centers. These photos will be used for the sole purpose of promoting, reporting, or publicizing the work and programs of Signal Centers. Such promotion may include the use of my participant’s name and picture in newspaper or other print media/promotions, DVDs, television news, and/or the Agency’s website. I also give my permission for observations of my child to be conducted and research and statistical data collected, so long as confidentiality of information is maintained.
Yes
No
Participant's Name
Print Parent/Guardian's Name
English
English
English