This Camp Is for Visually Impaired Novice Horseback Riders Between the Ages of 16 and 24

Enchanted Hills Camp Application 2015

Horse Camp

Sunday, August 2 -- Saturday, August 8

This camp is for visually impaired novice horseback riders between the ages of 16 and 24 years old, with no secondary disabilities. It is geared toward campers who have been on a horse before and have a bit of riding experience. Experience caring for horses is not required. Campers must have independent mobility skills to participate. This program is run by Diane Starin, a Living Skills Instructor at the Society for the Blind in Sacramento, California. To learn a little more about Diane Starin, please read the Instructor Bio and Objectives below.

Camper’s Last Name: ______First Name: ______Address: ______City: ______State:______

Zip: ______County: ______Email:______Phone: Cell: (____) ______Home: (____) ______Email: ______

Emergency Contact: ______Relationship______Phone: Cell: (____) ______Home: (____) ______Email: ______

Second Emergency Contact: ______Relationship______Phone: Cell: (____) ______Home: (____) ______Email: ______Name of O&M and/or TVI Instructor: Last______First ______Telephone Number: ______Email: ______

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Personal Information Date of Birth (MM/DD/YYYY):______

Gender: □Female □Male

Ethnicity (optional):______(This information is important for grant and funding applications, which assist in defraying costs for your attendance.)

Primary Language: ______

Secondary Language: ______

Do you have a roommate preference?  Yes  No

If yes who do you desire as your roommate? ______

(Please note that these are requests and we will attempt to fulfill them but we do not guarantee requests. These requests are honored by availability.)

Tell us about your hobbies and interests: ______

______

Referral Information:

Referred by:

Teacher Family Member Friend Other:

(If other who or what?): ______

DOR Counselor (if applicable):

Counselor First Name: ______

Counselor Last Name: ______2

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Telephone Number: ______

E Mail: ______

Are you a Regional Center Client? Yes No

If “Yes”, Name of Regional Center: ______

If “Yes”, Name of Case Manager: ______

Camp Participation Restrictions: Do you tire easily?  No  Yes (please explain) ______Can you participate in walks up to an hour long?  Yes No Can you swim independently in a pool of 3-foot depth?  Yes No 6-foot depth?  Yes  No Can you swim independently without a flotation device?  Yes No Any other restrictions? ______

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Horse Riding Ability and Interests Questionnaire

1. What is your riding history? ______

2. How often do you ride? ______

3. Have you ever owned a horse before? Yes_____ No____

4. Do you have any fears around horses? Yes_____ No____

5. What are your interests in horse camp? ______

6. What movies have you seen or books have you have read on the topic of horses? ______

7. Have you ever taken riding lessons? Yes_____ No_____

8. If so, please name the discipline and provide any other details that apply. ______

9. Do you have a favorite breed? Yes_____ No______

10. How comfortable are you around horses? (Please choose from the following answers:

Not confident and comfortable ______Somewhat confident and comfortable______Mostly confident and comfortable______4

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Extremely confident and comfortable______Camper Questionnaire

VISION: Cause of visual impairment: ______

Age of onset: ______If partially sighted, please describe your functional vision: ______

How do you prefer to access print material? Braille Tape Large Print  Email COMMUNICATION/ SPEECH: Verbal: Non–Verbal: If non–verbal; please describe method of communication: ______

HEARING: Are you hearing impaired?  Yes  No

Do you use hearing aids? Left Ear ______Right Ear ______

For communication, which do you use?

 Sign Language  Finger Spelling  Verbal  Other

If other please describe: ______

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired MOBILITY: Are you an independent traveler?  Yes  No Do you use: Battery Wheelchair Non-Battery Wheelchair Support Cane White Cane  Human Guide Guide Dog

If you are a wheelchair user; can you use your chair on unpaved trails?  Yes  No If you are a wheelchair user; can you transfer independently?  Yes  No

DAILY LIVING SKILLS:

For dressing: No assistance needed  Some Assistance needed (Please describe): ______

For eating:  No assistance needed  Some Assistance needed (Please describe): ______

For bathing: No assistance needed  Some Assistance needed (Please describe): ______

For toileting: No assistance needed  Some Assistance needed (Please describe):______

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired PLEASE RETURN THIS FORM

TRANSPORTATION

Let us know how you will get to and from camp.

Getting to camp:

____ I will get to camp by private car

$25 to Camp ($40 Round Trip)

I would like to take the charter bus from: ____ San Francisco departs @ 1:00 p.m. from the LightHouse, 214 Van Ness Ave. ____ Berkeley departs @ 1:30 p.m. from Ed Roberts Campus, 3075 Adeline Street

Getting back from camp: ____ I will leave camp by private car

$25 to Return from Camp ($40 Round Trip)

I would like to take the charter bus back to: ____ San Francisco arrives @ 12:15 p.m. @ the LightHouse, 214 Van Ness Ave. ____ Berkeley arrives @ 11:15 a.m. @ The Ed Roberts Campus, 3075 Adeline Street

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Driver Release Form

If the camper is age 17 or under, and someone other than the parent or guardian may be picking them up from camp, the parent or guardian must complete and sign the following driver’s release. .

I hereby authorize: ______or______to pick up my child, ______, from Enchanted Hills Camp. I understand EHC staff will check the identification of the driver prior to releasing my child.

Parent/Guardian Signature ______

Please Print Your Name ______Date______

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Payment Info

Please note: YOUR APPLICATION WILL NOT BE PROCESSED WITHOUT PAYMENT AND COMPLETE APPLICATION  I have already contacted the Enchanted Hills Camp Program Assistant, at (415) 694-7310 and made a credit card payment.  Enclosed is a check or money order. Enclosed is a Regional Center Authorization Financial Hardship, please contact Tony Fletcher, EHC Director @ 415-694-7319

Send applications and payment to:

Enchanted Hills Camp Application LightHouse for the Blind and Visually Impaired 214 Van Ness Avenue San Francisco, CA 94102

If you have questions, please contact: Enchanted Hills Camp Program Assistant at (415) 694-7310

Camp Fees*:

$300.00 Horse Camp Session Fee ______

Charter Bus Fee ($25 one way, $40 roundtrip) ______

$10.00 Camp T-shirt ______

Total: ______

*All cancellations are subject to a $50 non-refundable administration fee. Cancellations received 30 days or more prior to the start of camp will be refunded, less

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired the administration fee. Cancellations received less than 30 days prior to the start of camp are not refundable.

Self-Disclosed Health Form

Name: ______

Birth Date: ______Sex: _____ Height: ______Weight: ______

Please indicate the following health conditions:

Yes No Explanation ______History of heart disease______High Blood Pressure ______Constipation/diarrhea______Coordination problems______Dizziness/fainting______Arthritis______Respiratory problems______Circulatory problems______Frequent colds/sore throats______Mental Health ______Muscle weakness______Kidney problems ______Headaches______Joint/muscle pain______Seizure disorder ______Orthopedic problems______Vomiting______Shortness of breath______Diabetes (Type) ______Traumatic Brain Injury______Other______

What is the primary cause of your vision loss? ______

Age of onset? ______

Please describe your visual impairment? ______10

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired ______

Self-Disclosed Health Form

Who is your Primary Care Physician? Last Name: ______First Name: ______

Telephone Number: ______

Current Medications, including over the counter medications: Drug Dosage Frequency ______

Current Treatments: Condition Treatment ______

Past Medical Treatment: ______

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Drug Allergies:

Are you allergic to any medications prescribed or over the counter medications?  Yes  No

If yes, what are they? ______

Please describe what reaction you have had and how have you been treated in the past? ______

Food Allergies:

Are you allergic to any foods?  Yes  No

If yes, what are they? ______

Please describe what reaction you have had and how have you been treated in the past? ______

Are you on a special diet?  Yes  No

If yes, what type of diet are you on? ______

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired OTHER DISABILITIES: (Please check any of the following that apply)

____ Cerebral Palsy

____ Multiple Sclerosis

____ Diabetes (type): ______

____ Epilepsy (date of last seizure): ______Type of seizure: ______

____ Head Injury (please describe): ______

____ Cognitive Disability (please describe): ______

____ Developmental Disability (please describe functioning level, living skills, etc.): ______

____ Mental Health History (please describe):______

___ BEHAVIORAL DISORDER: (Self-abuse, biting, hitting, wandering, insomnia, etc. Please be specific and explain any behavior management routine you would like us to implement at camp) *Note a camper who harms another camper or staff member will be immediately dismissed from camp. ______

___ Attention Deficit Disorder or Hyperactivity (please describe):______13

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired ______

___ Serious illness or injury that has required hospitalization (please describe): ______

___ Other (please describe): ______

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Self-Disclosed Health Form

Date of last tetanus shot: ______Must have been completed in the last ten years

Tuberculosis: Date of last TB test:  Negative  Positive (Only applicable if living in a residential facility)

Do you have any physical conditions requiring restriction(s) on participation in an active recreation program? Please explain. ______

If camper is under the age of 18 years old, by signing this document you (the parent/guardian), are attesting that All immunizations for your child; that is required for school, are up to date; including the actual date (month/year) of last tetanus shot.

______Date

______Consumer Name (PRINT)

______Consumer Signature

______Parent/Guardian (PRINT)

______Parent/Guardian Signature

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired *Please note Self Disclosure must be signed and dated.

Medical Insurance Form

______Name of insured ______Name of insurance carrier ______Membership number Expiration date (if any)

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired LightHouse for the Blind and Visually Impaired

Agreement and Understanding of Financial Responsibility For Medically Uninsured Consumers of the LightHouse, Enchanted Hills Camp

Camper Name: DOB: ______

Date: ______

All persons who participate in programs sponsored by the LightHouse are responsible for having their own medical insurance and are liable for their own medical coverage in the event of an injury. Because you do not have medical insurance, it is important that you understand and agree with the following. (Please initial each number if you are in agreement and sign below.)

1. _____ Because I, , am uninsured by any medical insurance coverage/group, it is the understanding of the LightHouse for the Blind and myself, that I am responsible for ALL medical fees & medications prescribed/incurred if emergency medical services are necessary and provided by qualified medical personnel.

2. _____ When participating in the Enchanted Hills Camp program, and if I am in need of emergency medical services due to injury, the Camp Nurse and Camp Director will instruct that I be sent to The Queen of the Valley Hospital, Napa, CA. However, if medical personnel require I be sent to another facility for treatment, the Camp Nurse or Camp Director of the Enchanted Hills Camp must follow their direction.

3. _____ I understand I will be unable to attend Enchanted Hills Camp, Napa, CA unless #1 & #2 are initialed.

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired "I understand and am in agreement with the information on the previous page, and I take FULL responsibility for those items (1 - 3), which have been initialed."

______Name (print) Signature

1. Camper Phone Number: ______

Camper Address: ______

______

2. Parent/Guardian Phone: ______Home

______Work

3. Other Emergency Contact: ______Name Relationship

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired Phone Number: ______Home Work

Instructor Biography and Objectives

Diane Starin is currently a Living Skills Instructor at the Society for the Blind in Sacramento, California.

Diane grew up in Nebraska and lost her vision at the age of eighteen months. She attended the Nebraska School for the Blind until she was in the ninth grade.

At the age of fifteen she moved with her mother to Sacramento, where she attended High School at McClatchy.

Diane has an Associates of Science degree in Agricultural Business, a Certificate in Horse Husbandry and is a certified Therapeutic Riding Instructor.

She has had a Quarter Horse Breeding business and has owned and ridden horses since she was twelve years old.

Diane started working for the Society for the Blind in August 2004. She taught Living Skills in the Senior Impact program until February of 2007, when she started the fulltime position that she holds today.

Objectives for Horse Camp

1. Teach safety.

2. Teach grooming.

3. Teach tacking up.

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired 4. Teach good care and maintenance.

5. Expand camper’s knowledge of different kinds of equipment and their different applications.

6. Riding and lessons as time and skill levels allow.

LightHouse for the Blind & Visually Impaired WAIVER OF LIABILITY & RELEASE This Waiver of Liability and Release must be initialed after each section and signed by anyone receiving services from the Lighthouse for the Blind & Visually Impaired (Lighthouse) at the following locations: 214 Van Ness, LightHouse of Marin, LightHouse of the North Coast, Enchanted Hills Camp, LightHouse Industries, in the community, client's home and workplace, as well as, while being transported in a vehicle provided or procured by the Lighthouse. Participation in services is prohibited unless this form has been signed and returned to the individual receiving services or participating in LightHouse program is “Active.” If more than a year passes without activity in ANY LightHouse program or service, a new Waiver MUST be signed.

1) I am in satisfactory physical, mental and emotional condition and may engage in all activities associated with the services I am receiving at my own risk, except those listed in number 7 below. At any time that I am receiving services provided by the Lighthouse, I hereby consent to any medical and/or other treatment as may be considered necessary by a qualified physician, nurse, or designated Lighthouse staff member. In case of emergency, permission is given to designated Lighthouse staff to contact emergency medical services and/or secure treatment for the undersigned. 20

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired ______Initials

2) I hereby state, that even with the best optical correction that I am: ____ A. Visually impaired (visual acuity between 20/40 and 20/200) and have a vision loss that significantly limits one or more life functions. ____ B. Legally blind (visual acuity of 20/200 or less in best corrected eye, or visual field of 20 degrees or less). ____ C. Totally blind or nearly-totally blind (visual acuity of "hand motions," "light perception," or "no light perception.") I understand and accept the Lighthouse reserves the right to require documentation of my vision loss if the Lighthouse staff determines such information is considered necessary for assessment and/or the provision of services/training. ______Initials 3) I hereby waive any and all claims that I or my heirs may have against the Lighthouse, its Directors, Officers, Employees, Independent Contractors, Volunteers, and/or Agents for any injuries or property damage which may arise while I am receiving Lighthouse services, including transportation provided or procured by the Lighthouse, at or while en route to any of the locations referenced above in paragraph 1. I acknowledge that this waiver includes any claims for personal injuries or property damage caused by or arising out of the negligence of Lighthouse or its Directors, Officers, Employees, Independent Contractors, Volunteers, and/or Agents. ______Initials

4) A major objective of the Lighthouse is to educate the public about blindness. To accomplish this, the Lighthouse frequently sends press releases and photographs to the media (newspapers, radio, television and the internet). It is the right of the individual whether 21

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired or not to consent to the use of her/his photograph and/or name for the above publicity purposes. I hereby authorize the Lighthouse to use any photographs taken at the Lighthouse of me and/or my property. Yes No ___

5) I hereby authorize the Lighthouse to use my voice or written communications for publication, fundraising and advocacy purposes. Yes No ___

6) Are there any medical, mental or emotional conditions and/or medications the Lighthouse should be aware of during your participation in programs/services with the Lighthouse? If so, please explain. ______

7) Exceptions or specifications regarding any of the above: I understand this Waiver of Liability and Release constitutes the entire understanding between the parties referenced herein with respect to matters set forth herein. There are no oral representations, arrangements or agreements between the parties referenced herein other than those contained verbatim in the Waiver of Liability and Release. ______Initials

This Waiver of Liability and Release shall be interpreted in accordance with and governed by the laws of the state of California.

______Date

______Consumer Name (PRINT)

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired ______Consumer Signature

______Parent/Guardian (PRINT) (Required if consumer is under 18 years old)

______Parent/Guardian Signature

Enchanted Hills Camp is a program of the LightHouse for the Blind and Visually Impaired