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\ Rehabilitation Camps and \ \ v Children's Hospital Colorado ^ ^ Outdoor Programs ^

CamPossible: For Children with Cerebral Palsy

CamPossible is a camp for children with varying types of with cerebral palsy. Focus is placed on developing positive self-esteem, and the confidence to explore new activities and adventures! Children live, work, and play in a "family" group of 6-8 campers, 2-3 outdoor educators from the Breckenridge Outdoor Education Center, and 2 specialized therapists (Occupational Therapist, Physical Therapist, or Speech Therapist) from Children's Hospital Colorado. Therapists and staff members will assist with adapting activities as needed, and promoting a successful experience for all campers. Campers will assist with the daily routines of meal preparation and clean-up. Their days will be filled with opportunities to go: rock climbing, canoeing, to a ropes course and hiking. In addition to this, there will be crafts and group games. CamPossible promotes motor skills, coordination and balance, problem solving, self-confidence, and friendship.

Eligible Participants CamPossible I: Designed for children 8-12 years of age with cerebral palsy who are able to walk without the use of adaptive equipment (walkers, crutches, etc.), braces excluded. o Does not have significant cognitive or language limitations o Must be fully independent with toileting skills and be able to use an outhouse during camp, o Is able to walk long distances (2-3 miles) without assistance , braces excluded o Must be able to follow instructions and comply with adult requests o Must be able to remain in a group of 13 people without constant 1 on 1 attention o May not have extreme emotional and/or psychological distress o Must have recommendation from occupational or physical therapist for involvement in CamPossible

CamPossible II: Designed for children 8-14 years of age with cerebral palsy who are mobile with the use of adaptive equipment including walkers, crutches, and wheelchairs. o Does not have significant cognitive or language limitations o Must be able to use a toilet with minimal assistance from an adult o Must be able to move around environment using least restrictive assistive device with minimal assistance from adults. o Must be able to follow instructions and comply with adult requests o Must be able to remain in a group of 13 people without constant one on one attention o May not have extreme emotional and/or psychological distress o Must have recommendation from an occupational or physical therapist for involvement in CamPossible

CamPossible(720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045 Session Information Camp will be held in the Old Cabin and/or The Lodge at the Breckenridge Outdoor Education Center. 2017 CamPossible: Session I: June 18th-20th Session II: July 14th-16th

Transportation

Please note that families are responsible for transportation to and from camp.

CamPossible takes place at: Breckenridge Outdoor Education Center (BOEC) in Breckenridge, Colorado. (1 hour 45 minutes west of Denver)

Funding $550 Cost to Families

CamPossible cost to families for our 2017 season is $550. This cost includes lodging, outdoor activities and all meals.

Scholarship assistance may be available, so please don't let camp costs deter your child from participating

Additional funding may be available via qualification and completion of the Financial Assistance Application included in this camp application. CamPossible is financed solely by income obtained through donations and various fund raising efforts. Every attempt is made to make financial assistance available for individuals with identified needs. Resources for camp scholarships are subject to the amount of funds raised each year for this purpose. Camp fees are not billed to insurance providers.

Application Process: Due by Monday April 30th , 2017. Children's Hospital Colorado Attn: Ashley Busacker 13123 East 16th Aveirae, Box 285 | Aunrora, CO 80045 Or fax to 720-777-7297 (Attn: Ashley) Or email to [email protected]

All applicants will be screened for appropriateness and must meet all of the requirements for involvement. Priority will be given to applications that are 100% completed and on a first come basis. You will receive a written notification of acceptance by middle of May.

• Children's Hospital Colorado Camp application a The Physician Permission form must be completed by your child's primary care physician ® Therapist Recommendation Form • BOEC Participant Application (1 page- front/back) • Optional: The Financial Assistance application

CamPossible (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045 Camp Application

CAMP SESSION I: • CAMP SESSION II: •

Please fill out this application completely.

Demographic Information:

Name (please print)

Describe the services your child currently receives in school, including therapy or special education supports:

List any people you give permission to pick your child up from camp:

Describe the services your child currently receives in school, including therapy or special education supports:

School: Grade: Teacher: Medical History:

3. Name of child's doctor Phone # 4. Within the last year, has your child had any illnesses, injuries of surgeries If yes, please list and explain

5. List any medical diagnoses 6. Date of last physical examination: Date of last tetanus immunization: 7. If your child has had any of the following conditions, please circle and give details at tine end of the section: • Any problem with vision or hearing - - . Frequent infections of throat, tonsils, requires glasses, hearing aid, etc. sinuses, ears. • Problems with teeth — use of braces, etc. • Chronic cough, bronchitis, bloody sputum. • Dizzy spells, fainting, convulsions, . Asthma or respiratory problems, persistent headaches, anxiety or vertigo. . Palpitation of the heart, irregular heartbeat, heart murmurs, etc.

CamPossible (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus 113123 East 16th Avenue, B285 | Aurora, CO 80045 • Poor circulation • Reaction to extremes of temperature, previous ® Jaundice or hepatitis. frostbite, poor circulation, etc. • Frequent abdominal cramping or severe • Allergy to medicines, foods, insect bites, bees, menstrual cramps. etc. ® Difficulty urinating, pain on urination, bed • Diabetes, thyroid trouble, bleeding problems. wetting. • Incontinence. • Frequent diarrhea or blood in stools. • Sleep walking. • Kidney infection or stones. • ADD (Attention Deficit Disorder), ADHD • Spasticity, rigidity, poor muscle tone or (Attention Deficit Hyperactivity Disorder). limited range of motion • Other significant medical or neurologic • Catheter/leg bag disorders. • Broken bones, joint dislocations, serious • Any medications for diabetes, seizures, or sprains. blooding thinning. ® Any severe injury to chest or internal ® Memory Loss organs. • Non-Verbal • Chronic skin problems, rashes, infections, etc.

Seizures/Epilepsy: Date of last seizure Type of seizure Current status (active or controlled) Duration How often Describe reaction before, during and after seizure

Details of other conditions

Medications (please list all):

Name of Medication Dosage Times Given Total Doses per day Reason for medication

How does he/she take the medication (chew, swallow with liquid, swallow with food, etc.)?

Do we have permission to give your child Aspirin or Tylenol in the case of a headache or minor pain? • Yes nNo • Call first Self help skills:

1. Can your child dress himself/herself completely without help? • Yes • No (If no, what does your child need help with?

CamPossible (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus 113123 East 16th Avenue, B285 | Aurora, CO 80045 2. Does your child need any help with hygiene? • Yes • No (If yes, what?) 3. Is your child fully potty trained? • Yes • No Does your child have any bowel or bladder trouble? • Yes • No

Does your child wet the bed? nYes DNO Would your child be willing to use an outhouse? nYes nNo

Therapy:

1. Is your child currently receiving therapy? • Yes • No If yes, what is the frequency of the treatment? Occupational Therapy per month Therapist Phone # Physical Therapy per month Therapist Phone # Speech Therapy per month Therapist Phone # Other _per month Therapist Phone # 2. Has your child had any of the above therapies in the past? nYes nNo If so, please describe: (please include any current or previous therapy reports that will help us know more about your child)

Educational History:

My child: Is not yet in school _yes no Is having difficulty with schoolwork _yes no (If yes, please describe)

Receives special services: (list)

School: Grade: Teacher: Experience: 1. Please circle the appropriate response. Overnight Camping None Some Extensive Rock Climbing None Some Extensive Canoeing None Some Extensive Rafting None Some Extensive Swimming None Some Extensive Ropes Course None Some Extensive 2. Other related skills or interests: a) What does your child do well?

b) What is difficult for your child to do?

c) What activities does your child like to do?

CamPossible: CP Camp (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045 d) What activities does your child not like to do (or not do very often)?

3. Areas of Restriction: (please describe restriction) Swimming Athletics Overnight Camping Supervised ropes course Hiking Boating 4. Has your child attended any overnight camp before? yes no Why are you interested in having your child participate in this camp?

What would you like him/her to gain from camp?

Please share any other information about your concerns or your child's needs that would help our staff plan a more enriching experience for your child.

CamPossible: CP Camp (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045 Motor Qpestioimniianre Scoring Criteria: No = 0 - 25% of the time, Sometimes = 25% -75% of the time, Yes = 75% - 100% of time. Item No Sometii me§ Yes

Will use both hands to complete a task

Is able to open his or her non-dominant hand to grasp an object

Is able to extend and ami or leg to slow a fall

Is able to run

Is able to jump

Becomes anxious when feet are off the ground

Has a fear of falling or heights

Seeks out movement (fidgets a lot)

Has decreased awareness of one side of their body

Other have difficulty understanding what the child says

Becomes overly excited during movement activities

Limited attention

Tires easily or seems weak

Falls frequently or seems clumsy

Is able to get up from the floor or ground without assistance

Is able to go up and down stairs without assistance

CamPossible: CP Camp (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045 Physician Permission Form

Date :

Name Birth date

Address City Zip

Home Phone Work Phone

Parents/Guardians

Diagnosis/Reason for Referral _

Comments (include precautions)

I give my permission for the above named patient to participate in Children's Hospital Colorado Cerebral Palsy Camp (CamPossible) with Breckenridge Outdoor Education Center.

Physician's Signature:

Print Physician's Name:

CamPossible: CP Camp (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045 Financial Assistance Application (Optional)

Child's Name: Birth date:

Father's Name: Mother's Name: Marital Status: Married Single Divorced Separated (circle one)

Telephone: How long at present address?

Number of children in family: Ages:

Financial Information

Father's Employer: How long? Telephone: Father gets paid: Weekly Every 2 weeks Monthly (circle one) Amount of take home pay each pay period

Mother's Employer: How long? Telephone: Mother gets paid: Weekly Every 2 weeks Monthly (circle one) Amount of take home pay each pay period

Other sources of income and approximate dollar amount received from each source:

Checking Account Balance (approximate): Savings Account Balance (approximate):

CamPossible: CP Camp (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045 Expenses Original Balance Current Balance Monthly Payment 1. House Payment or Rent

2. Utilities (gas, elec., water, phone) 3. Groceries 4. 5.

6.

Has your child received Camp Financial Assistance previously? List any other resources you have, or are in the process of contacting, for financial assistance for camp (such as local service organizations, like Kiwanis, or town or county community boards or groups):

Estimation of amomntt family cam pay; $

I hereby certify the above to be true to the best of my knowledge.

SIGNATURE:

CamPossible: CP Camp (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045 Therapist Recommendation Form

Date:

Name of Child: Child DOB:

Therapist Completing this Form:

Phone:

Do you recommend this child for the camp program for children with cerebral palsy?

What are the child's current therapy needs and goals?

What would you like to see this child accomplish at camp?

What approaches or techniques help this child succeed?

Please keep in mind primary criteria for camp acceptance. The child must be 8 years old, fully independent with toileting and willing to use an outhouse, able to follow instructions given by an adult and comply with adult requests and be able to remain with a group of 8 kids without constant 1:1 attention.

Please include any current evaluations with this form. You can return this to the family or send it directly to:

Children's Hospital Colorado Attn: Ashley Busacker 13123 East 16th Avenue, Box 285 | Aurora, CO 80045 Or fax to 720-777-7297 (Attn: Ashley) Or email to [email protected]

CamPossible: CP Camp (720) 777-3456 Children's Hospital Colorado | Anschutz Medical Campus | 13123 East 16th Avenue, B285 | Aurora, CO 80045

BRECKENRIDGE OUTDOOR EDUCA TION CENTER PA R T1CIPA NT A PPLICA TION TOR ALL PARTICIPANTS IN BOEC PROGRAMS

The following information assists the BOliC in maintaining a risk-managed environment. Please complete this form as accurately and truthfully as possible. This information will be confidential.

Course/Group Name Course Dates

PERSONAL IN FORMA TION - Participant (Please print legibly)

Name

Mailing Address

City State Zip

Phone (home) Phone (work)

Phone (cell)

Email Address Age Birth date Gender

Dietary Restrictions: Please include all food allergies and preferences (examples: gluten free, vegetarian, eel..)

Ethnic Origin: (This section is optional. We gather this information to gage our effectiveness in reaching a diverse clientele. Please check appropriate box.)

African American Hispanic Asian American Native American Caucasian Other

EMERGENCY CONTA CT:

Name Relationship

Address

City State Zip

Phone (home) (work) (cell)

Name and phone number of Adult(s) allowed to pick-up participants

***Please note: the above line applies to participants being picked up directly from the BOEC and not campers departing with a partnering agency.

INSURANCE IN FORMA TION Is the applicant covered by any medical care policy? (Circle answer) YES NO

Medical Insurance Policy (carrier and type) Policy Number

S:\WILD\PROGRAM\Paperwork\Application Paperwork\Group WILD paperwork\Current & Old Forms\Current Student Applications\Summer Participant [ Application and Medical form revised 2-15.doc OVER (Please note: We recommend that all BOEC students be covered by personal health insurance. If medical care for injury, pre-existing condition or any other reason is required during a BOEC course, the student's personal health insurance will be primary.)

MILITARY SERVICE MEMBER Yes No If Yes, Branch: Rank: Is the disability combat or active duty related? Yes No Where injury occurred:

MEDICAL IN FORMA TION A physician's approval to participate in a BOEC program is not required. The BOEC strongly encourages you to consult your physician if you have concerns or questions regarding your ability to participate in an outdoor experiential program. We are happy to answer any questions that you or your physician have concerning BOEC activities and/or adaptations that are frequently a part of BOEC programs.

PLEASE ANSWER THE FOLLOWING QUESTIONS: (Fill in blank or circle as appropriate.)

Height: Weight: Challenge/Diagnosis

Do you have any limitations that you believe will affect your ability to participate in a BOEC program? YES NO Please List:

Are you under any treatment for any illness or condition? ' If so, please name and describe:

Are you currently taking any form of medication? If so, please give name, dosage, and frequency:

Do you have any allergies? If so, please list them and include allergic reactions to medications:

Have you recently undergone surgery or had a sever illness? If so, please describe the procedure or illness:

Do you smoke? YES NO If YES: How much?

Do you exercise regularly? YES NO Please describe your exercise program.

Please check off any of the following conditions you have or have had in the past and give the year of occurrence:

• Asthma • Dislocation • Back Pain • Sprain • Chest Pain • Fracture • Epilepsy • High Blood Pressure • Diabetes • Headaches • Heart Disease • Difficulty Breathing

Are there any other conditions or concerns not listed above? Please explain:

Please circle the answer for the following questions:

Strength: Upper Body: Poor Fair Good Lower Body: Poor Fair Good

Will you bring your own adaptive equipment? YES NO Wheel chair Walker Cane Other

Have you ever attended a BOEC program before? YES NO