Please Return Completed Application No Later Than June 1, 2017

WASHINGTON STATE DEPARTMENT OF SERVICES FOR THE BLIND

PROGRAM INFORMATION

Please return completed application no later than June 1, 2017.

Camp Dates:Monday, July 17 through Friday, July 21, 2017

Time:10:00 am – 3:00 pm

Location:Delta DeltaDelta
4527 21st Ave. NE
Seattle, WA 98105

Submission Methods

By mail:

Janet George

Department of Services for the Blind

3411 S. Alaska Street

Seattle, WA 98118

By email:

Contact information:

If you have questions about completing this application or about the SKILLS camp, please contact:

• Janet George 206-906-5529,
• Aileen Mattsen 206-3008631,

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WASHINGTON STATE DEPARTMENT OF SERVICES FOR THE BLIND

SKILLS APPLICATION

Applicant Information

Applicant Name:

Social Security Number (last four digits only):

Home Address, including street, city, state, and zip:

Mailing address, if different than home address:

Birth Date:

Age as of July 1:

Gender:

Current School Grade:

Parent/Guardian Information

Parent/Guardian Name:

Home Address, if different from the student’s:

Mailing address, if different than home address:

Best contact phone number:

Second phone number:

Email address:

Put an X next to the format in which you prefer to receive materials regarding your child’s participation in SKILLS:

___Regular Print

___Large Print(font size: ____)

___Braille

___Electronic

Teacher of the Visually Impaired Information

Please provide the contact information of the TVI/O&M instructor your child currently works with so that we can contact them if we need additional information about your student’s O&M skills.

Teacher Name:

Name of School and School District:

Best contact phone number:

Email address:

Visual Impairment and/or Additional Disabilities

You may attach additional pages at the end of the application, if you need to provide more information.

Cause of vision loss:

Please check the legal description of your child’s vision:

☐Low vision☐Legally blind☐Totally blind

Describe best corrected visual acuities – distance:

O.D.20/____O.S.20/____O.U.20/____

Describe best corrected visual acuities – near:

O.D.20/____O.S.20/____O.U.20/____

If acuities are not applicable please place an X next to the appropriate description below:

☐Light Perception only ☐Waving Fingers, at _____ feet (distance)

Please describe how your child’s daily activities are affected by vision loss:

List and describe any other challenges associated with your child’s eye condition (for example, loss of field, light sensitivity, etc.):

Special Interests and Hobbies

Describe your child’s hobbies and favorite recreation:

What does your child do for fun?

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WASHINGTON STATE DEPARTMENT OF SERVICES FOR THE BLIND

MEDICAL INFORMATION

Medical Conditions and Special Needs

To ensure the safety and well-being of all students, please provide full disclosure to the following questions. Lack of disclosure or incomplete information regarding medical, behavioral, or emotional issues that could potentially interfere with a student’s participation in program objectives, or that could affect the safety and well-being of SKILLS participants and staff, will be grounds for termination from SKILLS.

One at a time, list any medical conditions and describe how they affect your child’s daily activities.

Condition 1

Condition 2:

Condition 3:

Please list any allergies your child may have:

Food:

Medication:

Other: (e.g., to bees)

Please describe any dietary restrictions:

List any special accommodations and or services your child will need in order to participate in the SKILLS program (e.g., wheelchair access, interpreter, etc.):

Please use this space to share any other information that you feel would assist us in working with your child or that we need to know in order to determine if participation in the SKILLS camp is appropriate for your child.

Other medical conditions or facts which SKILLS staff and/or a medical practitioner should know:

Parent/Legal Guardian SignatureDate

Medications

If your child needs to take medication while attending SKILLS, please list the medication(s) and the dosage(s) below. SKILLS staff will monitor a child as s/he takes the medication. SKILLS staff will not administer the medication to the student.

STUDENTS MUST BE ABLE TO SELF-ADMINISTER OR PARTICIPATE IN THE ADMINISTRATION OF ALL NECESSARY MEDICATIONS.

A copy of the doctor's prescription must be on file with the SKILLS program before any medication can or will be dispensed by SKILLS staff.

I grant permission for my child to self-administer medications independently (SKILLS Staff monitoring only). Please initial ______

Please list any current medications your child is taking:

Medication name: / Dosage to be administered while at SKILLS

These Medical Treatment Authorizations are made on behalf of:

SKILLS Camper Name

Parent/Legal Guardian SignatureDate

Disclosure of Psychological and Behavioral Information

List any and all behavioral, social, and emotional condition(s) you child may have and describe how it impacts daily activities.

Condition 1

Please describe the effects of condition on your child’s behavior:

Condition 2:

Please describe the effects of condition on your child’s behavior:

Condition 1

Please describe the effects of condition on your child’s behavior:

SKILLS Camper Name

Parent/Legal Guardian SignatureDate

Emergency Medical Information

StudentInformation

Name:

Home Address, including street, city, state, and zip:

Parent/Guardian Information

Parent/Guardian #1

Home Address, if different from the student’s:

Best contact phone number:

Second phone number:

Parent/Guardian #2

Home Address, if different from the student’s:

Best contact phone number:

Second phone number:

Emergency Contact Information

Emergency Contact #1

Best contact phone number:

Second phone number:

Emergency Contact #1

Best contact phone number:

Second phone number:

Medical Insurance Information

Provider Name

Group or Policy Number:

Member or Subscriber Number:

Physician Information

Primary Physician:

Clinic Name:

Phone Number:

Parent/Legal Guardian SignatureDate

Permission for Emergency Treatment

In the event of an emergency, accident or illnessI, as the parent or legal guardian of the minor named below, hereby authorize the Department of Services for the Blind, its employees, and the staff of the SKILLS Program to administer emergency medical care for my child and/orto secure emergency medical services in case of illness or accident.

I agree to accept responsibility for payment of any medical care for my child that may occur during the SKILLS program.

SKILLS Camper Name

Parent/Legal Guardian SignatureDate

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WASHINGTON STATE DEPARTMENT OF SERVICES FOR THE BLIND

PERMISSIONS AND CONSENT

DSB Permission Share Information

NOTICE TO CLIENTS: The Department of Services for the Blind (DSB) can help you better if we are able to work with other agencies and professionals that know you and your family. By signing this form, you are giving permission for DSB and the agencies and individuals listed below to use and share confidential information about you. DSB cannot refuse you benefits if you do not sign this form unless your consent is needed to determine your eligibility. If you do not sign this form, DSB may still share information about you to the extent allowed by law. If you have questions about how DSB shares client confidential information or your privacy rights, please consult the DSB Notice of Privacy Practices or ask the person giving you this form.
CLIENT IDENTIFICATION
NAME / DATE OF BIRTH / LAST 4 DIGIT OF SS
OR ID NUMBER
ADDRESS:
TELEPHONE NUMBER (INCLUDING AREA CODE): / FORMER NAMES(S) USED:
CONSENT:
I consent to the use of confidential information about me within DSB to plan, provide, and coordinate services, treatment, payments, or for other purposes authorized by law. I further grant permission to DSB and the below listed agencies, providers, or persons to use my confidential information and disclose it to each other for these purposes. Information may be shared verbally or by computer data transfer, mail, or hand delivery.Please check all below who are included in this consent in addition to DSB and identify them by name and address:
☒SKILLS Directors Zac Small and Johanna Tracy
☐Mental Health Care Providers:
☐DSB:
☐Vocational Evaluation Information:
☐Housing Programs:
☐Department of Corrections:
☐Health Care Providers:
☐Social Security Administration or federal agency:
☐Community Rehabilitation Providers:
☐DSHS/DVR:
☐School Districts or Colleges:
☐student’s Teacher of the Visually Impaired (TVI):
Other:
I authorize and consent to sharing the following records and information (check all that apply):
☐All my client records
☐Records on attached list
☐Only the following records:
☐Family, social and employment history
☐Health Care information
☐Individual Assessments
☐Payment records
☐Treatment or care plans
☐School, education, and training
PLEASE NOTE: If your client records include any of the following information, you must also complete this section to Include these records. I give my permission to disclose the following records (check all that apply):
Mental healthHIV/AIDS and STD test results, diagnosis, or treatment (RCW 70.24.105)
Chemical Dependency (CD)services (42CFR2.32)
This consent is valid until December 31, 2017. I may revoke or withdraw this consent at any time in writing, but that will not affect any information already shared. I understand that once the health information I authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose, at which time it may no longer be protected under privacy laws. A copy of this form is valid to give my permission to share records.
SIGNATURE / DATE / AGENCY CONTACT/WITNESS SIGNATURE / DATE
PARENT OR OTHER REPRESENTATIVE’S SIGNATURE (IF APPLICABLE) / PHONE NUMBER (INCLUDE AREA CODE) / DATE
If I am not the subject of the records. I am authorized to sign because I am the: (attach proof of authority)
ParentLegal Guardian (attach court order)Personal representativeOther:

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WASHINGTON STATE DEPARTMENT OF SERVICES FOR THE BLIND

Permission to Transport

As the parent or legal guardian of child named below, I grant permission to the Washington Department of Services for the Blind to transport my child to activities and functions associated with the Summer Camp for Independent Living Skills.

Transportation may be provided by the following:

• State-owned vehicles
• County-owned vehicles
• Private shuttle company
• Commercial transportation (taxi)
• Public Transportation

SKILLS Camper Name

Parent/Legal Guardian SignatureDate

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WASHINGTON STATE DEPARTMENT OF SERVICES FOR THE BLIND

Photo/Video/Audio/Release Agreement

I hereby grant to Department of Services for the Blind (DSB) the right to publish, broadcast, webcast, or disseminate in any other form or medium any or all of the following:

•Stories and/or information about myself (or the minor of whom I am legal guardian) for use in news stories, publications, promotional materials, web features and/or any other agency purposes.

•Photographs, video, audio, and other images or likenesses of myself (or the minor of whom I am legal guardian) for use in news stories, publications, promotional materials, web features and/or any other agency purposes.

•All photographs, video, audio, images, likenesses, stories, and other materials will remain the property of DSB.

I have read and understood this agreement and I am over the age of 18. This Agreement expresses the complete understanding of the parties.

Printed Name

SignatureDate

WitnessDate

Parent/Guardian Consent

I am the parent or guardian of the minor named below. I have the legal right to consent to and do consent to the terms and conditions of this model release.

Minor/Student Name

SignatureDate

WitnessDate

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WASHINGTON STATE DEPARTMENT OF SERVICES FOR THE BLIND

THINGS TO BRING EACH DAY

•Remember to wear clothing that is comfortable and appropriate for current weather conditions!

•Wear shoes you can be comfortable walking in and are not afraid of getting dirty!

•Please bring any medication you will need to take during your camp time!

•Please bring sun block, and if you are very sensitive to sunlight, a hat!

•Remember to bring your Long Cane, campers who forget to bring theirs may not be able to go out with the group.

•If you have one please bring a backpack!

•Most important of all: Bring a great attitude!

If you have any question about what to, or what not to bring please contact Janet George or Aileen Mattsen for help!

•Janet George 206-906-5529,

•Aileen Mattsen 206-3008631,

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