Please Complete the Following Sections

South Hills YMCA CAMP A.I.M.

2017 REGISTRATION PACKET June 12, 2017 through July 21, 2017 9:00am-2:00pm

PLEASE COMPLETE THE FOLLOWING SECTIONS:

I. Camper Profile

II. Medical Information

III. Transportation/Billing

IV. Medical and Activity Releases

V. Camper Support Personnel

VI. Teacher Information Form

VII. Photo/Video Release Form

VIII. Medical Examination Form

PLEASE RETURN COMPLETED PACKETS TO THE P.O. Box LISTED BELOW. South Hills YMCA Camp AIM P.O. Box 578 Ingomar, PA 15127

REGISTRATION DEADLINE – APRIL 30, 2017 (Contact us to request an extension)

Contact Information: Address: Camp A.I.M., P.O. Box 578, Ingomar, PA 15127 Email: [email protected] Phone: Paulette Colonna, Camp Administrator (412)628-1121 2017 CAMP AIM Registration Tracy Herron, Emotional Support Unit Director (412)722-6322 Annemarie Bunch, Learning Support Unit Director (412) 913-0282

CAMP A.I.M. PROFILE

Our Campers: Our campers are special needs children and young adults from ages 5 to 21 who need physical support, have communication/social/sensory needs, have cognitive deficits and/or have emotional and behavioral challenges.

Camp Location: Camp A.I.M. is held at Carlynton High School Carlynton High School 435 Kings Highway Carnegie, PA 15106

Sessions/Costs: Camp A.I.M is composed of three, two-week sessions, taking place Monday – Friday from 9:00 am to 2:00 pm. Session 1: June 12 – June 23 Camper Fee: $575 Session 2: June 26– July 7 (off for July 4th) Camper Fee: $550 Session 3: July 10 – July 21 Camper Fee: $575

Transportation Fee(s): Range of Fee: $725+ per session (based on distance and vehicle availability)

There is a cost for transportation for some children. Children who are transported to Camp by their school district or brought to Camp by their parents incur no additional transportation fee. Some school districts offer transportation to Camp AIM at no cost to parents. Children who are transported to Camp AIM as arranged by Camp AIM will incur an additional cost that will depend on the actual cost of transportation. The range will be $725+ per session. This cost is affected by agreement with the school district, distance and vehicle availability. Parents should contact the Special Education department of their school district and check on transportation arrangements.

Responsibility for Payment: The first responsibility for payment to Camp A.I.M. is with the parents. Many school districts pay all of the costs of Camp. ESY services are covered by school districts. If you are unsure whether your school district will pay for Camp AIM, it is your responsibility to contact the school district.

Camp A.I.M. Staff The magic of Camp A.I.M. begins with its Staff. The Camp A.I.M. Administrative Staff averages more than 12 years of tenure at Camp A.I.M. and all are greatly experienced with high credentials in special education. In addition, Camp A.I.M. boasts of a very low staff to camper ratio with dedicated counselors who are mostly teachers and college men and women with an interest and commitment to special education.

2017 CAMP AIM Registration

*PLEASE NOTE THAT CAMP AIM DOES NOT PROVIDE LUNCHES. PLEASE SEND A LUNCH EACH DAY FOR YOUR CHILD.

CAMP A.I.M. REGISTRATION – PART I. Camper Profile

CAMPER’S NAME: ______LAST NAME FIRST NAME MIDDLE INITIAL

CAMPER’S ADDRESS: ______STREET ADDRESS CITY STATE ZIP

AGE (ON JUNE 12, 2017):______DATE OF BIRTH: ______GENDER: M F

MOTHER/GUARDIAN: ______LAST NAME FIRST NAME MIDDLE INITIAL PHONE HOME/CELL EMAIL

FATHER/GUARDIAN: ______LAST NAME FIRST NAME MIDDLE INITIAL PHONE HOME/CELL EMAIL

EMERGENCY CONTACT: ______LAST NAME FIRST NAME MIDDLE INITIAL PHONE HOME/CELL EMAIL

CAMPER’S PHYSICIAN: ______NAME PHONE

SCHOOL DISTRICT: ______

SPECIAL EDUCATION SUPPORT PROGRAM: ______

SCHOOL DISTRICT CONTACT PERSON: ______

ADDRESS: ______

PHONE NUMBER: ______

SCHOOL WHERE CHILD ATTENDS:______

TYPE OF CLASSROOM: LEARNING SUPPORT EMOTIONAL SUPPORT LIFE SKILLS SUPPORT AUTISTIC SUPPORT OTHER: ______

EXTENDED SCHOOL YEAR (ESY)

2017 CAMP AIM Registration Will your child be receiving ESY services at Camp A.I.M.? YES NO

DISABILITY/DIAGNOSIS: Asthma Emotionally Disturbed Muscular Dystrophy Attention Deficit Disorder Hearing Impairment Neurological Impairment Autism Spectrum Disorder Language Impairment Pervasive Developmental Delay Cerebral Palsy Learning Disabled Seizure Disorder Developmentally Delayed Intellectually Disabled Spina Bifida Down Syndrome Multiple Disabilities Visual Impairment

OTHER: ______

CAMP A.I.M. REGISTRATION – PART II. MEDICAL INFORMATION

CAMPER NAME: ______

CAMPER DISABILITY/DIAGNOSIS: ______

(PLEASE CIRCLE ALL THAT APPLY)

1. ADAPTIVE EQUIPMENT: WHEELCHAIR CRUTCHES WALKER ORTHOTICS WALKS WITH ASSISTANCE BRACES/TYPE ______OTHER: ______

2. METHOD OF COMMUNICATION:

VERBAL SIGN LANGUAGE COMMUNICATION BOARD INFORMAL GESTURES PICTURE BOOK OTHER: ______

1. FEEDING:

SELF FEEDS NEEDS FOOD CUT HAND OVER HAND TOTAL ASSISTANCE FINGER FOOD a. Special Utensils: ______b. Diet Restrictions: ______OTHER: ______

2. TOILETING:

SELFCARE NEEDS TRANSFERRED TO TOILET WEARS DIAPERS NEEDS REMINDED/TAKEN EVER _____ HOUR(S) OTHER: ______

3. DRESSING:

SELFCARE NEEDS SHOES TIED NEEDS MINIMAL ASSISTANCE NEEDS TOTAL ASSISTANCE OTHER: ______

2017 CAMP AIM Registration 4. SEIZURES:

Does your child have any history of seizures? YES NO Type of Seizure: Febrile Petit Mal/Grand Mal/Psychomotor If yes, does your child have a current history of seizures? ______How frequent are they? ______What is the usual length? ______OTHER Describe, if necessary: ______Does your child have a history of uncontrolled seizures (status epilepticus)? YES NO CAMP A.I.M. REGISTRATION – PART II. MEDICAL INFO (continued)

CAMPER NAME: ______5. ALLERGIES: Please list specifically to what your camper is allergic to and the reaction he/she has (such as a rash, watery eyes, runny nose, difficulty breathing, etc.) MEDICATIONS: ______Reaction Type: ______ANIMALS: ______Reaction Type: ______PLANTS, POLLENS, DUST: ______Reaction Type: ______FOODS ______Reaction Type: ______OTHER ______Reaction Type: ______Has your camper ever needed an adrenalin (epinephrine) shot to relieve difficulty breathing (anaphylactic shock)? YES NO

6. MEDICATION: MEDICATION MUST BE SENT TO CAMP ON MONDAY IN A PHARMACY LABELED BOTTLE FOR THE WEEK. EMPTY BOTTLE(s) WILL BE SENT HOME ON FRIDAY TO BE RETURNED TO CAMP THE FOLLOWING MONDAY. MEDICATIONS: Please list the name and dosage schedule of any medications your child is currently taking. Please be specific about how much medication is taken at each time.

2017 CAMP AIM Registration AMOUNT TIME TAKEN NAME: ______/______DOSAGE: ______/______

NAME: ______AMOUNT TIME TAKEN DOSAGE: ______/______/______

I HEREBY PERMIT THE YMCA TO DISTRIBUTE THE MEDICATIONS LISTED ABOVE AT PRESCRIBED DOSAGES To: ______CHILD’S NAME ______SIGNATURE OF PARENT OR LEGAL GUARDIAN DATE CAMP A.I.M. REGISTRATION – PART III. TRANSPORTATION/BILLING

CAMPER’S NAME______(PLEASE CHECK ALL THAT APPLY)

TRANSPORTATION ARRANGEMENT: PARENT OR GUARDIAN WILL TRANSPORT

SCHOOL DISTRICT WILL TRANSPORT

REQUEST THAT CAMP AIM PROVIDE TRANSPORTATION

PLEASE CONTACT ME TO DISCUSS TRANSPORTATION

ENROLL MY CHILD FOR: SESSION ONE (6/12 – 6/23) $575 CAMPER FEE

SESSION TWO (6/26 – 7/7 off for July 4th) $550 CAMPER FEE

SESSION THREE (7/10 – 7/21) $575 CAMPER FEE

CAMPER SUPPORT: MY CHILD WILL ATTEND CAMP WITH A T.S.S. OR SCHOOL DIST AIDE

MY CHILD WILL NOT ATTEND CAMP WITH A T.S.S. OR SCHOOL DIST AIDE EXTENDED SCHOOL YEAR:

2017 CAMP AIM Registration MY CHILD WILL RECEIVE ESY SERVICES AT CAMP A.I.M.

MY CHILD WILL NOT RECEIVE ESY SERVICES AT CAMP A.I.M. PARTY RESPONSIBLE FOR PAYMENT: Allegheny Intermediate Unit

School District

Parent

Other ______

SCHOOL DISTRICT BILLING INFORMATION (if applicable): SD NAME______ADDRESS ______CONTACT NAME ______PHONE ______

PAYMENT OPTIONS (if applicable) - Circle One Check Money Order Visa Discover Master Card American Express Card #______Exp Date ____/_____ CVV Code ______Full name on front of card ______

Billing questions, please contact Annemarie Bunch (412) 913-0282

PARENT SIGNATURE: DATE: ______CAMP A.I.M. REGISTRATION – PART IV. MEDICAL/ACTIVITY RELEASE

CAMPER’S NAME:

MEDICAL AND ACTIVITY RELEASES

In case of emergency: If the parents or guardians cannot be reached, please contact: ______NAME PHONE NUMBER RELATIONSHIP

______NAME PHONE NUMBER RELATIONSHIP

In the event that I cannot be reached IN AN EMERGENCY, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child as named here: ______CHILD’S NAME ______SIGNATURE OF PARENT OR LEGAL GUARDIAN DATE 2017 CAMP AIM Registration

I hereby permit the YMCA Camp AIM to release information regarding my child’s progress in camp and information supplied by me on the camp registration form. This information will be given to mental health staff and educational staff upon request. The purpose of providing this information is to insure continuous and coordinated effort by all professional staff working with your child in a variety of settings. ______CHILD’S NAME ______SIGNATURE OF PARENT OR LEGAL GUARDIAN DATE

I hereby give permission for my child to take part in swimming activities at Camp AIM. ______CHILD’S NAME ______SIGNATURE OF PARENT OR LEGAL GUARDIAN DATE

I give permission for my child to attend camp related field trips off of camp premises (prior to each field trip, the counselor will notify parents of destination). ______CHILD’S NAME ______SIGNATURE OF PARENT OR LEGAL GUARDIAN DATE CAMP A.I.M. REGISTRATION – PART V. SUPPORT PERSONNEL

CAMPER’S NAME:

If your child will be coming to camp with an aide from an outside agency, please complete the following: AGENCY NAME: ______PHONE: ______ADDRESS: ______ZIP ______CONTACT PERSON: ______NAME OF AIDE: ______

TYPE OF SERVICE:

COMMUNITY SUPPORT □

THERAPEUTIC SUPPORT STAFF (T.S.S.) □

2017 CAMP AIM Registration SCHOOL DISTRICT SUPPORT □

OTHER (EXPLAIN) ______

For organizational purposes of including aides from outside agencies into the program, we request that you share the following expectations with your agency and the aide before the start of camp:

1. Camp hours for aides are 8:30 AM – 2:00 PM. Aides are not permitted to leave camp during these hours.

2. Tennis shoes must be worn at all times. All other clothing should be appropriate for indoor/outdoor camp activities (including swimming, physical education).

3. Aides must participate in all activities with their child and the group (including swimming).

4. Aides should bring a lunch daily.

5. We request a copy of the goals or behavior management system that aides will use with their child (to help us integrate our goals with theirs).

6. Aides must wear photo identification cards at all times. This must include their name, picture, title, and agency.

7. Aides will be required to sign in and out daily on camp log book.

8. All camp policies (as listed in Staff Manual) must be adhered to by all staff (including aides). CAMP A.I.M. REGISTRATION – PART VI. TEACHER INFORMATION

TEACHER’S INPUT PAGE

CAMPER’S NAME: ______LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH: GENDER: M F

TEACHER’S NAME: ______

CONTACT NUMBER/EMAIL: ______

How has parental communication helped you in planning appropriately for this child’s programming? ______

2017 CAMP AIM Registration Please identify this child’s strengths. ______

Please identify the challenges that you face most often with this child. ______

What are some motivators that have worked when helping this child to manage his/her behavior? ______

How does the child get along with peers? ______

What do you hope that your student will gain from their experience at Camp A.I.M.? ______Please provide any additional information that you think would be helpful for Camp A.I.M. to better understand the needs of your student. ______CAMP A.I.M. REGISTRATION – PART VII. PHOTO/VIDEO RELEASE

YMCA of Greater Pittsburgh PHOTO AND VIDEO/AUDIO RECORDING RELEASE

I am 18 years of age or older and, if not, my Mother/Father/Legal Guardian has also signed below.

For my participation in activities to be conducted by YMCA of Greater Pittsburgh I hereby give my permission and consent, now and for all time, to YMCA of Greater Pittsburgh the National Council of Young Men’s Christian Associations of the United States of America (YMCA of the USA) and third parties collaborating with YMCA of Greater Pittsburgh and/or YMCA of the USA to make, reproduce, edit, 2017 CAMP AIM Registration broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Greater Pittsburgh, for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any compensation to, and/or claim, by me. I may, or may not be, identified in such reproductions; however, I shall not be stated by name to have endorsed any particular commercial products or commercial services.

I further agree to the following: - Any video film, footage, sound track recordings, and photo reproductions of me and/or my narrative account of my experience at YMCA of Greater Pittsburgh, I authorize, according to this Release, shall belong to YMCA of Greater Pittsburgh, YMCA of the USA and third parties collaborating with YMCA of Greater Pittsburgh and/or YMCA of the USA. Therefore, they will have full right of disposition of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA of Greater Pittsburgh;

- Any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA of Greater Pittsburgh will not be subject to any obligation of confidentiality and may be shared with and used by YMCA of Greater Pittsburgh, YMCA of the USA and third parties collaborating with YMCA of Greater Pittsburgh and/or YMCA of the USA;

- YMCA of Greater Pittsburgh, YMCA of the USA and third parties collaborating with YMCA of Greater Pittsburgh and/or YMCA of the USA shall not be liable for any use or disclosure to a third party of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Greater Pittsburgh; and

- YMCA of Greater Pittsburgh, YMCA of the USA and third parties collaborating with YMCA of Greater Pittsburgh and/or YMCA of the USA shall exclusively own all known or later existing rights to worldwide and shall be entitled to the unrestricted use any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Greater Pittsburgh for any purpose without compensation to me.

I agree that my consent and this release are irrevocable. I hereby release and discharge YMCA of Greater Pittsburgh, YMCA of the USA and third parties collaborating with YMCA of Greater Pittsburgh and/or YMCA of the USA from any and all claims in connection with the uses and reproductions of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA of Greater Pittsburgh as described herein.

Signature: ______Printed Name: ______

Age: ______Address: ______

I am the Mother/Father/Legal Guardian of ______(print child’s name). For the consideration contained herein, I hereby consent to the foregoing on behalf of my minor child.

Signature of Mother/Father/Legal Guardian: ______Date: ______CAMP A.I.M. REGISTRATION – PART VIII. MEDICAL EXAMINATION

CAMP A.I.M. YMCA OF GREATER PITTSBURGH – SOUTH HILLS YMCA MEDICAL EXAMINATION FORM

(PLEASE RETURN THIS FORM AFTER A DOCTOR HAS COMPLETED AN EXAM) 2017 CAMP AIM Registration We require a medical examination to be completed before your child will be accepted to Camp A.I.M. Your child will NOT be able to attend Camp A.I.M. without an up-to-date medical examination, including medical history, physician’s signature, and emergency contacts. If you will be sending your child to camp, please have the following form filled out by a physician.

CHILD’S NAME ______AGE ______

PRIMARY DIAGNOSIS ______

Before signing this form, please verify that the child is immunized for all of the following:

_____ Tetanus _____ Pertussis

_____ Diphtheria _____ Measles

_____ Polio _____ Rubella

_____ Mumps

I have examined the person described above and have reviewed his/her medical history. It is my opinion that he/she is physically able to engage in camp activities with any exceptions noted below: (these activities may include running or swimming)

Restrictions: ______

Doctor Signature ______Date______

2017 CAMP AIM Registration