Application Form for Summer Respite Day Camp

- Step 1 of 6

REGISTRATION INFORMATION

Summer Respite Day Camp 2023: July 4th – August 25th

9:00am-4:00pm

Price: $50 per week

Please complete the following form if you are interested in having your child attend the 2023 Yarmouth Association for Residential Community Options Summer Respite Day Camp.

Once you submit your registration, please await a confirmation of approval email that this camper is able to attend camp and which weeks they are registered for.

* Due to limited group capacity for participants, registration will be assigned on a first come first serve basis.

YACRO Respite Day Camp is open to school aged children living with physical/mental disabilities/illnesses.

ATTENDANCE PREFERENCE

Please select the weeks you wish for your child to attend camp.

We will only be accepting a limited number of participants each week. Low sensory weeks will have lower group numbers with a focus on quiet and calming activities.

For more details about weekly themes please contact Amy Sarginson.

*Most answers are compulsory. If a question does not apply, please just type "n/a" in the text box.

PREFERENCE *

Week 8: August 21-25 - Sports

Please select the weeks you wish for your child to attend camp.

* Although we may not be able to accommodate every choice, we will try our best to offer your preferences.

Order of Preference *

Additional Attendance Notes:

CHILD AND FAMILY PROFILE

Name *

Date of Birth: *

Source of referral: *

Other, please explain:

Parent(s)/Guardian(s) Name(s): *

Primary Phone Number: *

Secondary Phone Number:

Email Address: *

Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

I would like to receive information via: *

Phone
Email
Mail

I consent to Respite Day Camp Staff sending text information regarding this camper to my phone *

If "yes", what phone number should we text? *

Emergency Contact Name(s): *

Emergency Contact Phone Number 1 *

Emergency Contact Phone Number 2

Authorized Persons to Pick Up

Please indicate how many people other than yourself will be picking up your child from camp: *

None
1
2
3

First Authorized Person

First Authorized Person's Name: *

First Authorized Person's Phone Number: *

First Authorized Person's Relationship to Camper *

First Authorized Person Brief Description *

Second Authorized Person

Second Authorized Person's Name: *

Second Authorized Person's Phone Number: *

Second Authorized Person's Relationship to Camper *

Second Authorized Person Brief Description *

Third Authorized Person

Third Authorized Person's Name: *

Third Authorized Person's Phone Number: *

Third Authorized Person's Relationship to Camper *

Third Authorized Person Brief Description *

CHILD INFORMATION

Please take the time to answer these questions carefully

*Most answers are compulsory. If a question does not apply, please just type "n/a" in the text box.

Family Doctor: *

Other Professionals Involved: *

Diagnosis: *

Allergies: *

Medical Needs: *

Medications: *

Specific Concerns:

Please indicate the level of care that this camper requires: *

heavy
moderate
light

Does this camper require assistance with personal care? *

Please specify what aspects of personal care this camper requires assistance with: *

Strengths: *

Worries: *

Transportation: *

Are there any concerns we should be aware of in regard to this camper traveling in a vehicle? *

Transportation Concerns *

Communication

Please describe this camper’s method(s) of communication: *

Are they able to effectively communicate their wants and needs? *

Does the camper use visuals for communication? *

Visual Support: *

Sensory Information

Visual: *

Tactile/Touch: *

Auditory/Sound: *

Smell: *

Movement: *

Is this camper aware of their sensitivities? *

yes
no
not sure

How do they self-regulate? *

If they are not able to self-regulate, how can we best support this camper to regulate? *

Behaviors

Complex/Challenging Behaviors: *

Occurrence: *

Triggers: *

Intervention/supports: *

Strategies: *

Motivators: *

Transitions: *

Change in Routine: *

Flight Risk - Please identify if this camper is a flight risk: *

yes
no
not sure

1:1 Supervision - Please identify if 1:1 supervision is required at all times: *

yes
no
not sure

Activities/Hobbies

Enjoyed Activities: *

Disliked Activities: *

Outdoor Recreational Activities

What types of outdoor activities does this camper enjoy? *

Swimming: *

yes
no
not sure
has never been swimming
support required

Support Required: *

Life Jacket Required: *

Other

Please identify if this camper works better with certain types of people:

* Please note that this does not guarantee that the facilitator will fall within these categories, however, we will try our best to accommodate everyone as best as possible.

Please comment on any additional information that you feel is important for quality care of this camper:

What is this camper’s t-shirt size: *

Parent/Guardian Signature/Consent:

*By signing this form, I consent to sharing the above information regarding this camper with the Respite Coordinator and Respite Day Camp Staff.

Signature *

PARTICIPATION WAIVER AND CONSENT

I, the under signed parent/guardian of

Camper's Name *

do hereby consent to his/her participation in the Yarmouth Association for Community Residential Options and Autism Nova Scotia Summer Respite Program.

I acknowledge that participation in this program may expose the above named youth/child to the possibility of injury. I grant the YACRO and Autism NS Summer Respite Staff the authority to obtain emergency medical treatment as necessary to ensure that the above named child/youth is safe from further injury.

In consideration of YACRO and Autism NS and the permission to allow this child/youth to participate in its Summer Respite Program, I agree to waive and release Yarmouth Association for Community Residential Options and Autism NS from all claims for damages that may arise.

Parent/Guardian Name *

Parent/Guardian Signature *

Date *

MEDICATION AUTHORIZATION FORM

Medication will only be administered if it has been prescribed by a qualified medical practitioner, is in its original container and I have a signed permission form with directions.

parent/guardian, authorize YACRO and Autism NS Respite Coordinator/Summer Respite Staff to administer

(medication) to my child

with the following instructions:

Dosage *

Time *

Special Instructions (i.e. on full/empty stomach, etc.) *

Possible Side Effects *

Parent/Guardian Signature *

Date *

Family Service Agreement

*The Respite Coordinator will contact you directly to confirm your child’s spot in the Summer Respite Day Camp.*

YACRO continues to implement health and safety measures in accordance with public health guidelines to reduce sickness among participants and staff. If you or your child are experiencing illness, please stay home and return once well again. If your child becomes ill at camp, you will be contacted to come pick them up.

Staff will ensure all necessary sanitary measures are implemented throughout the day, such as proper hand washing, avoiding sharing, avoiding touching face, regular waste removal, frequent cleaning of highly touched surfaces, and regular cleaning checklists. Masks are not required by participants or staff.

Hours of Summer Day Camp will be 9:00am-4:00pm. Please ensure you arrive no earlier than 9:00am for drop off and no later than 4:00pm for pick up. You must sign in/sign out your child at the beginning and end of the day. Drop off and pick up will take place through the side door of the building located near the wheelchair ramp.

The cost of Summer Respite Day Camp is $50.00. Payment will be required upon registration to secure your spot.

Your child will require a packed lunch with snacks and water for each day. Please also send an extra set of clothes and any additional items your child will require throughout the day, ie. car seat, pull-ups, medications, sensory tools, communication devices, etc.

If you have any other specific concerns regarding this camper attending the Summer Respite Camp please contact Amy Sarginson at (902)742-9258 or respite@yacro.com

Parent/Guardian Name *

Parent/Guardian Signature *

Date *

TRANSPORTATION WAIVER

Child/Youth:

I acknowledge that the above named child/youth will be participating in activities and events organized by the Yarmouth Association for Community Residential Options and Autism Nova Scotia Summer Respite Staff. I am aware that the participation of my child/youth may be outside the scope of his/her regular routine. I give permission for my child to be driven by Summer Respite Staff/Respite Coordinator to a program location when the daily program activities require transportation.

I acknowledge and confirm that I have read this entire document prior to signing.

Parent/Guardian Name *

Parent/Guardian Signature *

Date *

CONSENT FOR PHOTO AND VIDEO

There may be activities during the YACRO & Autism NS Summer Respite Program where photos and videos may be taken. To do this we are asking your permission to photograph and/or videotape your child/youth when participating in Summer Program activities. YACRO hosts a Day Camp Blog on our website located at respite.yacro.com. Some of the photos taken throughout the Summer could be used on the website's blog, as well as social media, and for other promotional purposes.

MY CONSENT TO SHARE PHOTOS/VIDEO *
YES, I do consent
NO, I do not consent

Parent/Guardian name *

parent/guardian of

Child's Name *

give my permission for my child to be photographed or videotaped in a group or individual setting by the YACRO Summer Respite Program staff, and used on the YACRO Respite Blog.

Parent/Guardian Signature *

Date *

* Fill the spaces below ONLY to deny your consent to share photo/video.

I *

parent/guardian of

Camper's Name *

DO NOT GIVE my permission for my child to be photographed or videotaped in a group or individual setting by the YACRO Summer Respite Program staff, and used on the YACRO Respite Blog.

Parent/Guardian Signature *

Date *

For Office Use Only:

Respite Coordinator

Date Received

REGISTRATION INFORMATION

Summer Respite Day Camp 2023: July 4th – August 25th

9:00am-4:00pm

Price: $50 per week

Please complete the following form if you are interested in having your child attend the 2023 Yarmouth Association for Residential Community Options Summer Respite Day Camp.

Once you submit your registration, please await a confirmation of approval email that this camper is able to attend camp and which weeks they are registered for.

* Due to limited group capacity for participants, registration will be assigned on a first come first serve basis.

YACRO Respite Day Camp is open to school aged children living with physical/mental disabilities/illnesses.

ATTENDANCE PREFERENCE

Please select the weeks you wish for your child to attend camp.

We will only be accepting a limited number of participants each week. Low sensory weeks will have lower group numbers with a focus on quiet and calming activities.

For more details about weekly themes please contact Amy Sarginson.

*Most answers are compulsory. If a question does not apply, please just type "n/a" in the text box.

Please select the weeks you wish for your child to attend camp.

* Although we may not be able to accommodate every choice, we will try our best to offer your preferences.

CHILD AND FAMILY PROFILE

Authorized Persons to Pick Up

First Authorized Person

Second Authorized Person

Third Authorized Person

CHILD INFORMATION

Please take the time to answer these questions carefully

Specific Concerns:

Communication

Sensory Information

Behaviors

Activities/Hobbies

Outdoor Recreational Activities

Other

Parent/Guardian Signature/Consent:

PARTICIPATION WAIVER AND CONSENT

MEDICATION AUTHORIZATION FORM

Family Service Agreement

TRANSPORTATION WAIVER

CONSENT FOR PHOTO AND VIDEO

For Office Use Only:

For more information regarding respite support please contact:

Amy Sarginson

Contact Us

For more information regarding respite support please contact:

Amy Sarginson

Contact Us