Zajac Ranch CNIB Application 2018
Zajac Ranch for Children
CNIB Camp Application Form
Dear Parents/Guardians:
Thank you for your interest in the Canadian National Institute for the Blind (CNIB) summer camp session at Zajac Ranch for Children. This camp is held in partnership with Zajac Ranch for Children and BC Blind Sports and Recreation Association. We are welcoming children and youth who are blind and partially sighted, ages 8-18 from all over B.C. and western Canada.
Please read the following information carefully. To apply for camp, you MUST submit a COMPLETED APPLICATION FORM. Be certain to review the checklist below to be sure you have included all the necessary information. Incomplete applications will not be processed until all required information; along with the camp fee payment is received.
Bus transportation will be arranged to and from a location that is near the CNIB office on Joyce Street in Vancouver and returning from Zajac Ranch. CNIB travel subsidies are available to BC clients for travel from outside the Lower Mainland.
All applications will be reviewed by the Zajac Ranch Nursing Director, who will contact you with any questions/concerns. Acceptance letters and pre-arrival information will be sent by email to the address you provide. If no email address is provided, this information will be mailed.
CHECKLIST: Your application must include:
ð Current photo of the camper (to quickly identify your child and their needs) *Very important
ð General Information – name and contact information
ð Signed Consent for Medical Treatment
ð Signed Photo/Video Release Form
ð Complete General Medical History
ð List of Current Medications
ð Completed Physical Care Requirements
ð Medical Form COMPLETED – STAMPED – SIGNED by a physician
ð Payment Detail Form (cheque attached or credit card) or completed Zajac Community Partners Subsidy application with required documentation attached
Submit completed application to:
Vanessa Bailey, Program Lead, Children and Youth Services
CNIB Vancouver
200 – 5055 Joyce Street
Vancouver, BC V5R 6B2
Email:
Phone: 604-431-2121 Extension 6018
Fax: 604-431-2099
CAMP SESSIONCNIB Camp
(for children age 8-18 who are blind or partially sighted)
Sunday, July 8, 2018 – Saturday, July 14, 2018 / Has camper attended Zajac Ranch before? / Yes # of years ____
No
Year of last camp attended
CAMPER APPLICANT INFORMATION
First Name
/ /Last Name
/ /Gender
/MaleFemale
Nickname
/ /DOB (DD/MM/YYYY)
/ /School Grade
/123456789101112OtherN/A
Address
/ / City / /Province
/Postal Code
/ /Phone
/( ) -
/First language
/Diagnosis(eye condition):
/ /Weight (in lbs)
/ (for equestrian director)Preferred format
/ Large Print: Braille: OtherT-Shirt Size
/ PLEASE CHECK ONE: Adult XXL: Adult XL: Adult L: Adult M: Adult S:Youth XL: Youth L: Youth M: Youth S:
Care Card #
/ /Doctor’s Name
/ /Doctor’s #
/( ) -
Hospital
/ /Specialist’s Name
/ /Specialist #
/( ) -
PARENTS/GUARDIANS INFORMATION – LIST MAIN, PRIMARY CONTACT FIRSTName / Relationship / Home Phone / Cell Phone / Email
1 / ( ) - / ( ) -
2 / ( ) - / ( ) -
If camper does not live with all guardians listed above, which has legal custody?
EMERGENCY CONTACT
(if parents/guardians can’t be reached) / Name / Relationship / Work Phone / Home/Cell Phone
( ) - / ( ) -
PICK-UP (if someone other than a parent/guardian will pick up) / ( ) - / ( ) -
How did you hear about Zajac Ranch for Children (Please check appropriate boxes)
Medical Organization
/ /Referral
/ /Social Media
/School
/ /Website
/ /Other
/Did you attend a Zajac Open House?
/ /Yes
/ /No
/ /GENERAL MEDICAL HISTORY
Drug Allergies: Please list all allergies or indicate "none" if none exist: None
Type of reaction (e.g. Anaphylaxis, rash, etc.):
Dietary Allergies/Restrictions: Please list all allergies/restrictions or indicate "none": None
Type of reaction (e.g. Anaphylaxis, rash, etc.):
NO OUTSIDE FOOD IS ALLOWED ONSITE WITHOUT CONSENT OF NURSING DIRECTOR – If your camper’s food
allergies/dietary concerns require food be sent, PLEASE approve with Nursing Director prior to arrival
Medical History: (include any other illnesses, medical problems, or special needs of your camper we should be aware of):
Has your camper recently been hospitalized / Yes / Date of Hospitalization: / Reason:
No
Are your child’s immunizations up to date / Yes No If no, which immunization(s) are missing?
Year of last Tetanus (dpt, dt): If your camper is not up-to-date with their tetanus immunization and they sustain a puncture wound while at Zajac Ranch, you will be called to take the camper, off-site, for any first aid.
My child is subject to, or has had:
ADD/ADHD / MigrainesAppendicitis / Mumps
Asthma / Rheumatic fever
Atlanto-Axial X-ray (please indicate results) / German Measles
Bronchitis / Chicken pox
Epilepsy / Ear infections
Diabetes / Eczema
Frequent colds / Tuberculosis
Hay fever / Seizures / Date of last seizure
Heart condition / Seizure Type
Hepatitis / Frequency
HIV / Normal Duration
Hypertension / Contact EMS after how long?
Kidney Disease / Other
Latex Allergy
Measles
PHYSICAL CARE REQUIREMENTS (Check all that apply)
Wheelchair / Amputation / Where?
Crutches/Cane / Artificial Limb / Where?
Walker / Splint/Brace / Where?
Blind / Hearing Impairment: / Left Ear
Partially Sighted / Right Ear
Explain sight restriction: / Hearing Aid(s)
Long white cane / Length: / Prescription glasses/sunglasses
ID cane / Additional lighting required
Does the camper require assistance in order to sit up independently? / Yes No N/A
Would the camper require a rest after walking the equivalent of 4 city blocks? / Yes No
Does your child require the use of a hospital bed? / Yes No N/A
Does your camper require a lower bunk? / Yes No
Does your camper have a bunk preference? / Top Bottom
Is your camper able to swim? Have they taken swimming lessons? / Yes No Level:
LEVEL OF ASSISTANCE FOR YOUR CHILD (Please check appropriate column for each category)
Independent / Some Assistance / Total Care
Daily Care (brushing teeth, combing hair, dressing)
Care of prosthetic eye(s)
Meals
Bathing/Showering
Toileting/Bathroom
Does camper have problems with bed-wetting? / Yes No
IF ‘Yes’ then how do you manage at home?
If the camper is female has she began her menstrual period? / Yes No
If YES to either of the above please provide enough supplies (plus a few extra) for the length of the whole camp.
COMMUNICATION
How does the camper communicate? / Verbal Complete Sentences 2-3 Words
Single Words Non-verbal
If your camper is non-verbal, please describe how he/she indicates
Hunger: / Happy:
Fatigue: / Discouraged:
Yes/No: / Anxious:
Hurt/upset: / A need to use the washroom:
Does your camper have any communication tools/devices they will bring to camp? / No
Yes – please specify
Additional Information/Comments:
SLEEP BEHAVIOURS
Camper has difficulty falling asleep? / No Yes
Camper has difficulty sleeping until morning? / No Yes
Camper wakes up easily during the night? / No Yes
Camper gets out of bed frequently during the night? / No Yes
Camper sleeps with light on? / No Yes
Camper makes a lot of noise at night? / No Yes
Camper sleepwalks? / No Yes
Describe a normal bedtime routine:
BEHAVIOURAL CONCERNS (Please select all that apply)
Punching/Hitting / Risk to Others
Running / Risk to Self
Attention Seeking / Easily Frustrated
Sensitive to Noise / Homesickness
Other, Please list:
Please describe triggers for behaviour and early signs of escalation:
What’s the best way of supporting the camper when they are showing early signs of distress:
Has camper been away from home before: No Yes
If Yes, how long: / Has camper done overnight camps before?
No Yes
SUPERVISION
How often does the camper require close supervision? Please provide accurate examples.
All of the time Some of the time None of the time
Additional information and/ or comments:
DIETARY CONCERNS / EATING HABITS
Please describe camper’s eating habits: / Fussy Average Hearty
Additional Information/Comments (if ‘fussy’, please describe what camper eats at home and how you encourage camper to eat):
Please note - If the camper’s food allergies/dietary concerns require food be sent, this has to be pre-approved by the Nursing Director. If dietary/food allergies are not accurately relayed here, camper may be sent home upon arrival.
SOCIAL AND EMOTIONAL ADJUSTMENT QUESTIONNAIRE
How does your camper interact in a group of peers?
Prefers to be by self? No Yes / Prefers not to be touched? No Yes
Bothered by excessive noise? No Yes / Grabs or touches other people? No Yes
Need to know the schedule? No Yes / Uses inappropriate language? No Yes
Does your camper actively participate in group activities? Will they participate if encouraged?
Interests/Hobbies: / Dislikes:
Please provide any other important information that would be beneficial for the Staff of the Zajac Ranch to provide the ultimate camp experience:
PERSONAL SUPPORT
Does/did the camper have EA Support at school? / No
Yes - for what reasons:
Does the camper require 1:1 care for any physical requirement or behaviour concerns? / No
Yes – please explain:
Additional Information/Comments:
If 1:1 support is required, is the family able to provide 1:1 support?
Please note: family appointed PSWs must complete a separate form / No
Yes, name of PSW:
If the camper has experience, was a ZR 1:1 support provided? / No
Yes, what year?
DISCLAIMER: Any camper not identified as needing 1:1 support prior to arrival at camp and identified as requiring 1:1 support will be sent home. All Family Appointed PSWs must submit a PSW Application Form prior to approval. Parents/Grandparents may not accompany campers to camp, but other family members may.
Medical Form
(To be completed & stamped by a licenced physician
within 6 months of camp start date)
The person being evaluated will be attending one week of camp. The experience may include sleeping on the ground and participating in activities such as hiking, canoeing, and large group games.
Date of Exam:Patient’s name: / DOB:
Primary Diagnosis:
Secondary Diagnosis:
Drug Allergies:
Other Allergies:
Please list any surgeries below
Date: / Procedure:Date: / Procedure:
Date: / Procedure:
Date: / Procedure:
PHYSICAL EXAM: Please list any pertinent findings OR attach a recent H&P
Age: / Weight (LBS): / Height:Blood Pressure: ___/___ / Pulse: / Vision:
LEFT EYE: Normal Partial Sight Glasses Contacts Light Perception No Light Perception
RIGHT EYE: Normal Partial Sight Glasses Contacts Light Perception No Light Perception
Hearing: Normal Abnormal If ‘Abnormal’, please explain:
Please list any Dietary Needs:
Regarding this individual’s social development; would they communicate and interact with peers and others in an age appropriate manner? Yes No
If no, what additional supports are needed to make this a successful camping experience?
Are there any behavioural concerns that would affect this individual’s participation in a group? Yes No
If ‘yes’, please explain:
Does this individual have any physical or medical concern that would make horseback riding not appropriate?
No Yes - please explain:
I, ______(physician name), have examined ______(name of individual) and find her/him able to attend camp.
______
Signature of Physician Print Name Date PHYSICIAN STAMP
ALL medications administered at camp (including over-the-counter medicines and vitamins) must be written on this form. All medications/other supplies necessary for use while at camp will be stored and administered by medical staff as directed by you. Please send all medications in their original bottles, properly labelled with your camper’s name. They must have correct pharmacy labels.
Drug Name and Strength / Dose / Frequency / Time of Day
Supplemental Nutrition
Please indicate any special ways to give medications. Include information about medications used to prevent nausea and vomiting and pain management if applicable. We know that medication schedules may change before the summer; please inform us if changes occur after this form has been submitted.
The Registered Disability Savings Plan
Since 2012, FS Financial Strategies have donated over $15,000 to Zajac Ranch for Children through their Mission of Care program. FS Financial Strategies are trusted partners of Zajac Ranch and we are pleased to tell you about their program One Less Worry. One Less Worry aims to provide a safe and compassionate environment for people with disabilities and their families to learn more about the options available to them to achieve financial security. They have helped hundreds of families to register for the Registered Disability Saving Plan (RDSP) and helped ensure they are receiving the additional financial support they may be eligible for, once registered for the Disability Tax Credit.
If you would like to find out more about the Registered Disability Saving Plan we would encourage you to contact Kay Wheeler at FS Financial Strategies to arrange a Mission of Care appointment. (A quick 30 minute free financial education session – no strings attached). Please indicate below or contact Kay Wheeler at (604) 209-2128 (cell) or .
I have a Registered Disability Saving PlanI would like more information about the Registered Disability Saving Plan
I would like Kay from FS Financial to contact me regarding the Registered Disability Saving Plan
By attending a financial education session, FS Financial Strategies will donate $100 on your behalf to Zajac Ranch for Children through their Mission of Care program.
CAMP FEESThe fee for all CNIB campers is $50. Please select payment method below. DO NOT SEND CASH.
PAYMENT OF CAMP FEESCheque enclosed (please make cheque payable to CNIB)
Credit Card (please complete details below)
Type of card VISA/MasterCard American Express
Name on Card
Card Number / Expiry date / MM/YY
I authorize CNIB to charge $50 to the credit card listed above
Signature of cardholder Date (DD/MM/YYYY)
(form continues on next page)
I, ______(Parent/Guardian full name or Camper’s name if over 18), hereby give permission for The Mel Jr. & Marty Zajac Foundation (“The Zajac Foundation”), Zajac Ranch for Children, CNIB, and BC Blind Sports and Recreation Association to use photographs/videos taken of my child/myself, ______(Camper’s name) during camp sessions for promotional, fundraising and/or editorial purposes.