Please check which camp(s) you are applying for: Camp SignalChatter CampVision Academy
Please check which date(s) you are applying for: June 12-16June 19-23June 26-30July 10-14July 17-21July 24-28
Please check which date(s) you are applying for: June 5-9
Please check which date(s) you are applying for: Young Adult Vision Camp: June 20-24Teen Vision Camp: July 11-15Elementary Vision Camp: July 25-29
First Name
Last Name
Preferred Name
Sex MaleFemaleOther
Ethnicity —Please choose an option—AsianBlackHispanicWhiteOther
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?
YesNo
(Parent's Initials)
At school, does your child require a one-on-one assistant?
Participant's T-shirt Size YSYMYLSMLXLXXLXXXL
Weight
Height
Mother First Name
Mother Last Name
Address
Primary Phone
Phone Type CellHomeWork
Secondary Phone
Do you live in the Chattanooga city limits?
Email
Employer
Father First Name
Father Last Name
First Contact Name
Relationship
Authorized to pick up?
Parent's Initials
Second Contact Name
Have a behavior plan? (If Yes, please provide a copy.)
Parent’s Initials
Run away or are they a “runner”? YesNo
If yes, are there triggers?
Exhibit self-injurious behaviors? YesNo
If yes, please describe those behaviors.
Is participant potty trained and/or needs help using the restroom? Please describe.
Wear glasses/contact lenses? YesNo
Use a wheelchair? YesNo
Crutches? YesNo
Walker? YesNo
Is the participant verbal? YesNo
Use a communication device? YesNo
If so, please list what system or app is being used?
Have emotional upsets? YesNoSometimes
If yes, what usually triggers emotional upsets?
What normally calms down the participant, if they become upset?
What are identified rewards or motivators for your child?
Do they have trouble communicating wants and needs? YesNoLimited Speech
Does the participant have allergic reactions, including allergies to food or environmental?
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?
—Please choose an option—YesNo
It is important for us to know if your child has any health problems so that we know how to best respond in case they should become ill while in our care. Please select the answer to each question that best describes your child and we will go over the checklist with you when you have finished.
1. Were there any problems with pregnancy or your child's birth? YesNo
2. Was his/her birth weight under 5.5 pounds? YesNo
3. Did your baby have any problems in the hospital? YesNo
4. Has your child ever been in the hospital overnight? YesNo
5. Is your child taking any medicine for a severe illness? YesNo
6. Any allergies or reactions to medication, DTP, other shots/insects? **Children with life-threatening allergies must have an ALLERGY ACTION PLAN** YesNo
7. Has your child had asthma or wheezing? **If your child has asthma, we must have an ASTHMA ACTION PLAN** YesNo
8. Does your child have speech or hearing problems? YesNo
9. Has your child ever had more than two ear infections in one year? YesNo
10. Has your child had tonsillitis? YesNo
11. Does your child have trouble with his/her eyes or seeing? YesNo
12. Has your child had a bladder or kidney infection? YesNo
13. Do they have seizures, fits, or shaking spells? YesNo
**If yes, please explain (may be required to have SEIZURE PROTOCOL on file**):
14. Have you ever been told that your child has a heart murmur? YesNo
15. Is your child able to play as hard as other children? YesNo
16. Has your child ever had a bumpy/swollen reaction to TB test? YesNo
17. Has your child ever been with anyone having TB? YesNo
18. Has your child ever had worms? YesNo
19. Is your child a hemophiliac (free bleeder)? YesNo
20. Is your child on a heart monitor? YesNo
21. Does your child have tubes in his/her ears? YesNo
22. Please list all childhood diseases your child has had:
23. Is your child in a special education class at school? YesNo
24. Are they usually happy? YesNo
25. Does your child have any special problems not indicated above? YesNo
If yes, please explain
Please tell us the date that your child last saw a doctor
Is there 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.)?
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)
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.
Participant's Name
Print Parent/Guardian's Name
English