\ \ \ 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