Camp Application

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Camp Application

    Camp Signal Director: Melissa Scannapiego
    Phone: 423-698-8528 EXT #701
    Email: Melissa_Scannapiego@SignalCenters.org

    Chatter Camp Contact: Beth Warren
    Phone: 423-298-8991
    Email: Beth_Warren@SignalCenters.org

    Vision Academy Director: Lana Little
    Phone: 423-298-8991
    Email: Lana_Little@SignalCenters.org


    Camp Application

    Please check which camp(s) you are applying for:

    Camp Signal

    Please check which date(s) you are applying for:

    Chatter Camp

    Please check which date(s) you are applying for:

    Vision Academy

    Please check which date(s) you are applying for:

    Participant Info

    Sex
    Do you give permission for Camp Signal Staff to discuss your child’s needs/interests with current teacher?

    (Parent's Initials)
    At school, does your child require a one-on-one assistant?
    Participant's T-shirt Size

    Parent/Guardian Info

    Mother

    Phone Type
    Phone Type
    Do you live in the Chattanooga city limits?

    Father

    Phone Type
    Phone Type
    Do you live in the Chattanooga city limits?

    Emergency Info

    Authorized to pick up?
    Authorized to pick up?

    Does the Participant?

    Have a behavior plan? (If Yes, please provide a copy.)
    Run away or is he/she a “runner”?
    Exhibit self-injurious behaviors?
    Wear glasses/contact lenses?
    Use a wheelchair?
    Crutches?
    Walker?
    Is the participant verbal?
    Use a communication device?
    Have emotional upsets?
    Does he/she have trouble communicating wants and needs?

    Health

    Does the participant have allergic reactions, including allergies to food or environmental?
    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?

    Health Checklist

    It is important for us to know if your child has any health problems so that we know how to best respond in case he/she 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?
    2. Was his/her birth weight under 5.5 pounds?
    3. Did your baby have any problems in the hospital?
    4. Has your child ever been in the hospital overnight?
    5. Is your child taking any medicine for a severe illness?
    6. Any allergies or reactions to medication, DTP, other shots/insects? **Children with life-threatening allergies must have an ALLERGY ACTION PLAN**
    7. Has your child had asthma or wheezing? **If your child has asthma, we must have an ASTHMA ACTION PLAN**
    8. Does your child have speech or hearing problems?
    9. Has your child ever had more than two ear infections in one year?
    10. Has your child had tonsillitis?
    11. Does your child have trouble with his/her eyes or seeing?
    12. Has your child had a bladder or kidney infection?
    13. Does he/she have seizures, fits, or shaking spells?
    **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?
    15. Is your child able to play as hard as other children?
    16. Has your child ever had a bumpy/swollen reaction to TB test?
    17. Has your child ever been with anyone having TB?
    18. Has your child ever had worms?
    19. Is your child a hemophiliac (free bleeder)?
    20. Is your child on a heart monitor?
    21. Does your child have tubes in his/her ears?
    22. Please list all childhood diseases your child has had:
    23. Is your child in a special education class at school?
    24. Is he/she usually happy?
    25. Does your child have any special problems not indicated above?
    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.)?
    YesNo
    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.

    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.

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