Join Us for a Family Weekend At

Join us for a Family Weekend at Camp Korey!What happens during a Family Weekend at Camp? The weekend includes:  Fun for the whole family! The weekend is full of Camp activities including campfire, fishing, arts & crafts, theater, climbing wall, and more)  A chance for parents and caregivers to connect with one another and build a network of support.  An opportunity to make friends! Family weekends are a chance for children (children living with an illness, as well as their siblings) to meet peers who are experiencing similar life experiences.Who is eligible? Any family with a child between the ages of 5 and 16 who is living with the condition we are serving that weekend (please check our seasonal schedule to see which groups we are serving this season!). WE welcome all family members who live in your household to join for a weekend filled with lots of fun!What is the cost? All Family Weekend programs are free of charge, thanks to the generosity of our partners and donors.Accommodations:  Families will be housed together in our camper lodges.  Each family will have their own private sleeping quarters and bathrooms.Medical coverage: A physician and several nurses will be on site throughout the weekend. While parents/caregivers will be responsible for day to day medical care of their children, our skilled medical team will be present and on-call for any medical needs and emergencies throughout the weekend.To apply: Complete the family application. This includes:  “Family Weekend Application.”.  “Family Medical Information” page for each family member who is coming (this does not need to be signed by a physician).  “Camper Medical Form” for the child with the condition we are serving that weekend. This form must be completed by a doctor or health care provider. If the child has attended a family weekend or summer camp at Camp Korey in the last six months, then a new camper medical form is not needed.Return the completed application to: Camp Korey- Camper Admissions 28901 NE Carnation Farm Rd. Carnation, WA 98014 425- 844-3226 Page 1 of 10 Fax to: 425-844-3123 E-mail to: [email protected] *We will notify you once we receive your application*Camp Korey Family Weekend Application1. What weekend are you applying for? Include condition group and dates: ______2. Please list family members attending:Camper with the diagnosis we are serving:Camper(s) Name: ______Birth Date: ______Gender: ______Diagnosis: ______Has your child or family previously attended Camp? � Yes When? ______� NoParent or Guardian Information:Parent or Guardian Name: ______Relationship to Camper: ______Parent or Guardian Name: ______Relationship to Camper: ______Phone(s): ______Email Address: ______Mailing Address: Street: ______City: ______State: ______Zip: ______Additional Siblings:Child’s Name: ______Birth Date: ______�Male � FemaleChild’s Name: ______Birth Date: ______�Male �FemaleChild’s Name: ______Birth Date: ______�Male �FemaleChild’s Name: ______Birth Date: ______�Male �Female3. Please explain any special needs your family has: (interpreter, first floor housing, dietary restrictions, etc.) ______Page 2 of 10 ______4. Emergency Contact: (other than family members attending the weekend)Name: ______Relationship to child: ______Phone: ______Alt. Phone: ______5. Clinic Information: What clinic or hospital do you typically go to?______Who are your child’s doctors?Specialist: ______Phone: ______Address: ______Pediatrician: ______Phone: ______Address: ______6. Photo Release and Special Permissions I give permission to Camp Korey and Camp Korey authorized news media to photograph and to use pictures, video, or audio tapes of my child and family members either alone or in groups for the newsletter, advertising purposes, fund-raising activities, bulletin boards, camp albums or in promoting public understanding and support for children with chronic medical conditions or serious illnesses, or substantially similar purposes. Camp Korey respects the privacy of its campers and their families and does not give permission for unauthorized visitors to photograph campers.Parent/guardian initials ______7. Feel free to share any additional information about your family: (fun facts, big news, interests, etc.) ______Return the completed application to: Camp Korey- Camper Admissions 28901 NE Carnation Farm Rd. Carnation, WA 98014 425- 844-3226 Fax to: 425-844-3123 E-mail to: [email protected]Due to the number of applications, not every family that applies can be accepted and may be placed on a waiting list. Notification of acceptance will take place 2-4 weeks prior to the Family Weekend.Page 3 of 10 Immunization Required for Family Weekends 2014THE FOLLOWING IS REQUIRED FOR ALL FAMILY MEMBERS AGE 18 AND BELOW: Diptheria, Pertussis, Tetanus (DTP, DTAP, Daptacel, Infanrix, Pediarix, Pentacel, Kinrix, TriHIBit, Tripedia) 5 doses (4 doses if 4th dose given at > 4 yr.) plus 1 dose Tdap required for > 11 yr. Hepatitis B (Engerix-B, Recombivax HB, Comvax, Pediarix) 3 dosesMeasles, Mumps, Rubella (MMR, MMRV, M-M-R II, ProQuad) 2 doses (1st dose at > 1 yr.)Polio (IPV, OPV, IPOL, Pediarix, Pentacel, Kinrix) 4 doses (last dose at > 4 yr., 3 doses if last dose given at > 4 yr.)Varicella (Varivax, Proquad) 2 doses (1st dose at > 1 yr., vaccine may be given as part of MMRV)Seasonal Influenza ( Required for primary camper only from Oct. 15, 2014 through April 15, 2015). Vaccine must be administered at least 2 weeks prior to attending the session.FOR IMMUNOCOMPROMISED / IMMUNOSUPPRESSED CAMPERS ONLY: ( e.g. , Transplant, Sickle Cell, Oncology):Pneumococcal Conjugate Vaccine ( PCV-13, Prevnar-13) 1 dose age 6 – 18 yr.Page 4 of 10 Camp Korey Family Medical InformationThis form must be completed for every family member coming to camp. Please make copies as necessary.Name: ______Birth Date: ____/____/______Age ______Mailing Address: (if different from address listed under contact information) Street: ______City: ______State: ______Zip: ______Phone: ______Please list any drug allergies: ______Please list food allergies or restrictions: ______Please list all medications: ______Please list any medical conditions, considerations, and/ or limitations: ______If family member is 18 years or younger please attach copy of child’s immunizations.Consent for Medical Treatment I hereby grant, in the event it is necessary, permission to the health care staff at Camp Korey, or consulting physicians; to obtain laboratory tests, x-rays, administer routine and other medication, and to provide any emergency or routine care required for: ______This form may be photocopied for use outside of camp.Signature: (Parent or Guardian of minors) ______Date: ______Relationship: (Self/ Parent/ Guardian) ______Insurance Information (Please complete or attach copy of insurance information)Name of Insurance Company______Policy Number or CIN# ______Medicaid Number (if applicable) ______Address ______Phone Number ______Prescription Plan (Co, ID#)______Page 5 of 10 If group insurance, specify company ______Name of parent who insures child ______Family Weekend Camper Medical InformationTHIS FORM MUST BE COMPLETED FOR THE CHILD WITH THE CONDITION WE ARE SERVING*Please note- if your child was a camper in our most recent summer program, and there have been no significant changes to his/her health, you do not need to fill out this portion of the application*PARENT TO COPLETE THIS SECTION Camper Name ______Date of Birth ______Primary Diagnosis ______Other Diagnose ______Significant past medical history/ other medical conditions: Is the child developmentally appropriate for his/her age?  Yes  No If no, at what (approx.) age does child function? ______List any communication problems or pertinent psychosocial and behavioral information that would affect the child’s participation in a group: ______Major surgeries ______Has the child been hospitalized in the last 6 months?  Yes  No If yes, please explain ______Does the child have Seizures?  Yes  No Type ______Duration ______Date of Last Seizure______Seizure Rescue Plan:______IMMUNIZATIONS: Please complete the chart below with dates or attach a copy of the immunization history. DTP/ DTaP 1. 2. 3. 4. 5. Tdap 1. IPV/ OPV 1. 2. 3. 4. Hepatitis B 1. 2. 3. Pneumococcal 1. 2. 3. 4. Varicella 1. 2. MMR 1. 2.Page 6 of 10 Camp Korey Family Weekend Camper Medical Information (continued)Allergies  NONE  Food ______ Meds ______ Other (Latex, bee sting, horses, etc.) ______Is cross contamination with small amounts of potentially allergy- producing food items a concern for your child?  Yes  No If yes, for which foods? ______Does the child require an epi-pen for any of these allergies?  Yes  No If yes, which?______Does the child have: Food Restrictions/ Special Diet?  Yes  No If yes, please explain ______Special Mobility Needs (e.g. wheelchair, walker, braces, etc.):  Yes  No If yes, please explain ______Special Infection Control Precaution:  Yes  No If yes, please explain ______Prescribed bladder/ bowel management program?  Yes  No If yes, please explain ______Consent for Medical Treatment I hereby grant, in the event it is necessary, permission to the health care staff at Camp Korey, or consulting physicians; to obtain laboratory tests, x-rays, administer routine and other medication, and to provide any emergency or routine care required for: ______This form may be photocopied for use outside of camp.Signature: (Parent or Guardian of minors) ______Date: ______Relationship: (Self/ Parent/ Guardian) ______Insurance Information (Please complete or attach copy of insurance information)Name of Insurance Company______Policy Number or CIN# ______Medicaid Number (if applicable) ______Address ______Phone Number ______Prescription Plan (Co, ID#)______If group insurance, specify company ______Name of parent who insures child ______Page 7 of 10 Camp Korey Family Weekend Camper Medical Provider FormTo be completed by health care provider (Physician/ Nurse Practitioner/ Physician’s Assistant) prior to submission of this application. Please be as detailed as possible and answer all questions. If child routinely has lab work, please attach most recent lab results.Today’s Date ______Camper Name ______Date of Birth ______Primary Diagnosis ______Other Diagnosis ______ALLERGIES: Drug______Other allergies (specify):______Does child have any of the following: Tracheostomy Feeding tube  Mitrofanoff Malone ACE Central access CPAP BiPAP Insulin pump Oxygen *If child has any of above, camp medical providers may contact you for additional information.VS: Ht (inch/cm) ______Wt (lb/kg) ______BP ______HR______RR______PHYSICAL EXAM: Check if NORMAL, or give details of abnormalities below.  HEAD: ______ EYES: ______ EARS: ______ NOSE/MOUTH: ______ TEETH: ______ NECK: ______ CHEST: ______ HEART: ______ ABDOMEN: ______ GENETALIA & RECTUM: ______NEUROLOGICAL: ______Page 8 of 10 MUSKULOSKELETAL: ______SKIN: ______BACK: ______Please add any additional details about the above issues that you feel will help us care for your patient: ______Special Diet (specify): ______Behavioral issues: ______No Yes Is the child developmentally delayed for his/her age? If yes, at what (approx.) age does child function? ______No Yes Special Mobility Needs (i.e. wheelchair, walker, braces, etc.): If yes, please explain ______Does the child have: No Yes An increased risk for injury from trauma? No Yes A known osteoporosis or past history of multiple fractures? No Yes A known risk for bleeding? If yes to any of the above statements, please explain: ______Is this child on: No Yes Coumadin/Aspirin or other antiplatelet therapy? If yes, what drug and dose? ______Major Surgeries (please attach summary): ______No Yes Has the child been hospitalized in the last 6 months? If yes, please explain: ______Please include a copy of the child’s discharge summary and most recent clinic note. Infection Control: No Yes Does this child have lapsed or incomplete immunizations? If yes, explain ______No Yes Varicella hx: Has the child had clinical evidence of chickenpox or shingles? If yes, when? ______No risk factors Negative Positive TB screening (PPD, IGRA)? If positive, explain ______No Yes Live vaccines deferred? If yes, explain ______No Yes History of MRSA infection? If yes, explain (including treatment) ______No Yes History of VRE infection? If yes, explain (including treatment) ______Page 9 of 10 List Current Medications or attach separate medication sheet ______Devices Central venous line/ Port-a-cath  Yes  No Type ______Location ______Tracheostomy  Yes  No Type/ Size ______Date of last change ______ CPAP  Malone/ ACE  Bile Tube  PE Tubes  Insulin Pump  BiPAP  G-Tube  Ostomy  Hearing Aids  Urinary Diversion (Mitrofanoff)  Oxygen  NG-Tube  J-Pouch  Glasses/ Contacts  VP ShuntPhysician/ Medical Provider’s Statement: I have examined ______and find him/her physically able to attend Camp Korey. I also verify that his/her primary diagnosis is ______I understand that the above treatment plan will be followed at Camp, unless other orders are received. Please include the most recent office note and a copy of this child’s immunization record. Signature ______Print Name ______Date ______If completed by a nurse: As the RN working with ______ MD  NP  PA I have reviewed the camper’s medical information and camp application with the child’s physician/NP/PA. He/she has given approval of all the information and recommendations reported on these camp medical forms and has given me permission to sign this form on his/her behalf. Clinic Name ______Hospital Affiliation ______Phone number ______Fax number ______Emergency/On Call Phone ______E-mail ______Any questions or concerns, please contact Please fax completed forms to: Annie Slater, MD 425-844-3105 Medical Director, Camp Korey [email protected]Page 10 of 10

Join Us for a Family Weekend At

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