Summer Social Skills Camp Program

SUMMER SOCIAL SKILLS CAMP PROGRAM

Program Handbook and Application

Keystone Behavioral Pediatrics

6867 Southpoint Drive North * Suite 101 * Jacksonville, Florida 32216

Telephone: 904.619.6071 * Fax: 904.212.0309

www.keystonebehavioral.com

INTRODUCTION

Our everyday environments present multiple social skills requirements that may overwhelm a child with a developmental disability. Children with challenges in this area may find themselves isolated, misunderstood, frustrated, anxious, or depressed. Others in their environment may perceive their social differences as an indication that they are rude, willful, awkward, or oppositional. Further, as these children transition into adulthood, social differences present challenges to successful employment, leisure, or relationship pursuits. Because of the pervasive impact of social differences, addressing social skills and social understanding is a critical part of the behavioral education curriculum for all children with developmental disabilities.

The Summer Social Skills Camp offered by Keystone Behavioral Pediatrics is a high quality program that provides instruction in a 5:2 student-to-therapist ratio, with behavior therapists trained in the methodologies and best practices of Applied Behavior Analysis. Upon completion of a behavioral assessment, staff will make recommendations pertaining to the anticipated level of support that your child will need to participate to the fullest extent. A variety of social skills domains will be addressed.

It is important to have a benchmark of the social skills and social understanding of individuals with developmental disabilities in order to provide targeted interventions. Instruments designed specifically for this purpose will be provided. Based on your child’s individual social skills assessments, your child will be assigned to custom social skills groups to address their core deficits. Once you have enrolled, a Social Responsiveness Scale (SRS) and the Social Skills Rating System SSRS) will be sent home for you to complete.

Dates of Operation

There will be 4 weeks of sessions offered. Dates are as follows:

July 1st- 5th, July 8th- 13th, July 15th- 19th, and July 22nd- 26th

July 2013
M / T / W / Th / F
1 / 2 / 3 / 4 / 5
8 / 9 / 10 / 11 / 12
15 / 16 / 17 / 18 / 19
22 / 23 / 24 / 25 / 26

Hours of Operation

Camp will be in session Monday through Friday, from 9:00 am to 2:00 pm. Before care will begin at 8:00 am. Aftercare will begin at 2:00 pm and will end at 6:00 pm.

Holiday

Keystone will observe the following holiday, and the camp will be closed: Thursday, July 4th, 2013.

ENROLLMENT REQUIREMENTS

1. The program is available to children between the ages of 3-18 years of age, diagnosed with a developmental disability. Only children whose parents/guardians have completed the registration process may be considered for acceptance into TKA’s Summer Fun Camp Program. All students enrolled in camp will have access to a variety of support services including:

· Individual Psychotherapy

· Psychological Evaluations

· Parent Collaboration

· Behavior Management

· High Functioning Social Skills Groups

· Sibling Support Groups

· Speech Therapy

· Occupational Therapy

· Applied Behavior Analysis

2. The following is required before registration:

[ ] $50 Registration Fee

[ ] Emergency Contact Information

[ ] Tuition Contract

[ ] Authorization for Medication

[ ] Student Photo Release Form

[ ] Social Skills Inventory

3. When Keystone Summer Social Skills Camp is at maximum capacity, parents may place their child(ren) on a waiting list to be notified when an opening becomes available. This will be done on a first come, first served basis.

4. All children in Summer Camp Programs must have proof of full coverage insurance.

FEES

· Program Fees are $400 per week. You may select which weeks you would like your child to be enrolled (e.g. all four weeks, the first and third week only, etc.)

· Payment for each week session must be made in advance.

· There is a Registration/Evaluation Fee of $50 per child. This fee is non-refundable.

· Please make checks payable to: Keystone Behavioral Pediatrics

· Payment may also be made by credit card.

· Any thematic units that involve paid admission to a site will be the parent’s responsibility (e.g. My Gym fees).

Missed Days/Partial Enrollment

There will be no refunds for days missed. If you are planning a vacation, please keep in mind that you will be required to enroll and pay for a minimum full week session. Partial enrollment of less than 3 days is not permitted.

Past Due Accounts and Returned Checks
Parents/Guardians will be responsible for restitution on returned checks, including fees and service charges (see billing policy). Only money orders will be accepted until returned checks and fees are paid in full. If payment is not made in full within five (5) days, or other arrangements made, the child will be ineligible to attend.

HEALTH AND MEDICAL INFORMATION

Sick Policy

In the event that a child appears to be sick, the Parent/Guardian will be called to pick him/her up immediately. Signs of illness include, but are not limited to: green mucous, fever, pink eye, diarrhea and vomiting. It is the responsibility of the Parent/Guardian to pick up the child within a reasonable amount of time. We will make every effort to promptly notify parents in the event of a breakout of contagious illness. For the protection of our campers, no child will be admitted to Keystone’s Summer Camp while he/she has a temperature. We need your help in keeping contagious diseases such as colds and flu out of the clinic. When your child is sick, you will be called to pick up your child as soon as possible. Children should not be sent back to the camp for at least 24-hours after they are clear of fever symptoms. Children in attendance should be well enough to participate in all activities. Parents must furnish medicine and adhere to the procedures listed below in order for staff to administer medications. The parent/guardian must complete a form, which is available in this packet. Teachers cannot fill out medicine forms or labels for you.

Medications

To enable clients to receive their prescribed medications during the camp day, a special medication/treatment form must be completed. This form requires the signature of the doctor prescribing the medication and the parent’s signature. Whenever possible, prescription medication should be administered at home. When a physician specifies that medication be administered during the camp day, the camp should be contacted, and the following guidelines will be used to supervise medication administration in camp:

· All medication should be brought to the office at the beginning of the day, by a responsible adult, accompanied by a signed and dated Emergency Card, giving Keystone permission to administer the medication.

· The medication must be in the original container, with a prescription label that includes the following information: the child’s full name, name of medication, prescription number, dosage, and time to be administered.

· Emergency medication will be administered when ordered by the family physician.

· Please notify the school of any medication changes.

· Children are not permitted to bring non-prescription medications to camp. If during the course of the day it is necessary for a student to receive non-prescription medication (i.e., Tylenol) our nurse will dispense the medication as indicated on the Emergency Card.

· Parents must notify Keystone of any allergies to, or restrictions on, non-prescription medications.

Keystone Summer Camp

Emergency Contact Information

Child’s Name: ______Name Called: ______

Date of Birth: ______Present Age: ______Sex: ______

Address: ______City: ______Zip: ______

(H) Phone: ______Household Email: ______

Mother’s Name: ______Occupation: ______Work Hours: ______

Home Phone: ______Work Phone: ______Cell Phone: ______

Father’s Name: ______Occupation: ______Work Hours: ______

Home Phone: ______Work Phone: ______Cell Phone: ______

Doctor’s Name: ______Phone Number: ______

Nearest relative or neighbor to contact in case of emergency, if parents cannot be reached:

Name: ______(H) Phone: ______(C) Phone: ______

Person authorized to pick up child. (Child can only be picked up by people on this list.)

Name: ______Relationship: ______Phone: ______

Additional person/people living or working in home: (include siblings)

______

Name & Age Name & Age Name & Age

Allergies: ______Fears: ______

Any health problems? ______Medication Required? [ ] Yes [ ] No

Medication taken regularly: ______

Please share any information that you think would be of help to our staff: ______

______

Keystone Camp Program

Tuition Contract

This agreement is made on ______(Date) between Keystone Behavioral Pediatrics and the Parent/Guardian, ______, with custody of ______who resides at the following address:

Address: ______City: ______Zip: ______

(H) Phone: ______(W) Phone: ______(C) Phone: ______

· I enroll my child(ren) for Keystone’s Summer Social Skills Camp Program

· I agree to pay $400 per week for this service as follows:

o ______$400 for Session #1 – due by Monday, June 24th, 2013

o ______$400 for Session #2 – due by Monday, July 1st, 2013

o ______$400 for Session #3 – due by Monday, July 8th, 2013

o ______$400 for Session #4 – due by Monday, July 15th, 2013

· I agree to pay a Registration/Evaluation Fee of $50 per each child enrolled in the program. I understand this fee is non-refundable, and is enclosed/attached to this application.

· I do not expect Keystones’ Summer Camp Program to provide medical insurance for my child(ren) nor will I hold Keystone, Director or staff liable for injuries which may occur in the normal provision of child care. I will provide my own medical insurance.

· I have read the attached policies and rules. Until these policies are changed, I accept them as they are and agree to abide by them.

Child(ren) enrolled:

______

Name & Age Name & Age

Payment Method:

______I wish to pay by check.

______I wish to pay by credit card:

______Visa ______MasterCard ______AmEx

Card Number: ______

Expiration Date: ______Security Code: ______

Parent/Guardian Signature: ______Date: ______

Print Name: ______

Keystone Summer Social Skills Program

Authorization for Medication

Date: ______

______

Student Name: Last, First Date of Birth Grade

MEDICATION TREATMENT PLAN TO BE COMPLETED BY PHYSICIAN

Diagnosis: ______

______

Medication, Dosage, Specific Times and Direction for Administration: ______

______

Note: Medication must be supplied in the original prescription container. Please ask the pharmacist to divide the prescription in two completely labeled containers, one for home and one for school.

Side Effects/Special Instructions: ______

______

Note to Physicians: Please complete the Treatment Plan on the next page for students who require any special health procedures during school hours (e.g. inhalers, nebulizer treatments, glucose testing, etc.)

______

Printed Name of Physician Physician’s Signature

______

Physician’s Phone Number Physician’s Fax Number

PARENTAL PERMISSION

I grant the Keystone Nurse or his/her designee the permission to assist in the administration of each prescribed medication/procedure to be provided during the school day.

______

Signature of Parent/Guardian Date Home/Work/Cell Phone

TREATMENT FOR CLIENT NEEDING HEALTH PROCEDURES DURING CAMP HOURS

Name of Student: ______Date of Birth: ______Grade: ______

Treatment Plan: ______

______

Special Procedures (List special procedures in which students have been trained: e.g. insulin administration, testing glucose, etc.): ______

______

Please list any limitations/precautionary measures that should be considered (e.g. physical activities or games, outdoor activities, transporting or lifting, special devices/equipment, etc.): ______

______

Please state any emergency precautions/health emergencies that should be anticipated for this student (e.g. allergy triggers, diabetic reactions, etc.): ______

______

What is the care plan for these identified emergencies? ______

______

Physician’s Signature Date

Keystone Social Skills Summer Camp Program

Client Photo Release

I, ______(Parent/Guardian) and my child ______(Child’s Name), a participant at the Keystone Social Skills Summer Camp program, do hereby give permission to Keystone to use my child’s photograph or photographic image in official Keystone business, including: Keystone web site, Keystone newsletters, etc. I understand that photographic or video images will be used for news organizations and promotional purposes.

I hereby waive any right that I may have to inspect or approve the finished product in which a photographic or video image may be used including the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied.

I hereby release, discharge, and agree to save harmless Keystone, its officers, employees, attorneys, representatives, and all persons acting under its permission or authority or those for whom acting from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of said picture or video or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.

This release contains the entire agreement between the parties and shall be binding upon and inure to benefits of its successors and assigns of the undersigned.

Signed this date ______/ ______/ ______

______

Student’s Printed Name

______

Parent’s Signature

______

Parent’s Printed Name