Texas 4-H Conference Center staff and volunteers serving during Mission ... get the doctor to call in a new prescription
July 6-8, 2017 Texas 4-H Conference Center
Thank you for your application to Mission Possible! To ensure we can adequately meet each campers’ needs, please complete this form and return either by mail to the Texas 4-H Conference Center, 5600 FM 3021, Brownwood, TX 76801, fax to 325/784-6486 or email
[email protected]. Applications are accepted until camp is full. Please read carefully and follow the instructions as printed. Additional information regarding your camper is requested to provide a better camping experience for your son or daughter. The information will be kept in strict confidence and will only be shared with Texas 4-H Conference Center staff and volunteers serving during Mission Possible. Your attention to detail and sharing of information will help us in providing a comfortable and pleasing experience for all involved. If you have any questions or would like to speak with someone in person, please contact Dr. Darlene Locke, at 979/845-6533 or e-mail
[email protected] Sincerely,
B. Darlene Locke Extension Specialist, 4-H Youth Development 4180 State Hwy 6 College Station, TX 77845 979/845-6535
[email protected] Educational programs of the Texas A&M AgriLife Extension Service are open to all people without regard to race, color, sex, religion, national origin, age, disability, genetic information or veteran status. The Texas A&M University System, U.S. Department of Agriculture, and the County Commissioners Courts of Texas Cooperating.
Mission Possible Medication Policy and Procedure Please read carefully Please bring your camper’s medications in the original prescription labeled container. It is suggested that you only send the amount of medication needed for camp (three days, two evenings). State requirements will not allow us to keep your camper and administer the medications unless you bring the original medication containers with the correct prescription label to camp. Follow the same procedure for over-the-counter medications, vitamins, and supplements. Bring liquid medication(s) in the original container(s). If a prescription label is incorrect on a container, we will need a signed note from the doctor with the correct information. Upon arrival at camp, you will give all medications, both prescription and non-prescription, to the nurse on duty. Please provide a list, either typewritten or hand printed, of the medication and dosage, and time to be dispensed. This will be reviewed by the nurse at check-in. Example of Medication Instructions: Camper’s Name: Ima Happy Camper Time of Dose: 0800 Breakfast Depakote 125 mg, 2 capsules Multivitamin, 1 chewable Time of Dose: 2100 Bedtime Depakote 125 mg, 2 capsules Frequently asked questions: 1. What if my camper has medications that are not pills, such as liquids, powders, inhalers, and creams? Bring the medication in the original labeled container. Please make sure there is enough to make it the duration of camp. 2. What if my camper’s meds come in a “blister pack” from the pharmacy? Blister packs are a sheet of cardboard with a plastic bubble for each dose of medication and you just push the medication to get it out. Just bring the blister packs, making sure the label on the blister pack is correct. This is considered the “original container”. 3. What if the medication container does not have the correct dose amount or times? We realize that sometimes the amount or times change. If this happens, there are two ways to fix it. You can get the doctor to call in a new prescription and have new labels printed at the pharmacy, or get the doctor to write a note with the correct information and sign it. It must have the doctor’s signature and the date on the note. We are not allowed to give medications differently than what the doctor has ordered. 4. What if my camper has meds they only take occasionally, as needed? Bring those in their original, labeled containers. This includes any over-the-counter medications. 5. What if I forget or don’t have my camper’s original medication bottles? Unfortunately, we will not be able to legally dispense the medication, thus
YOUR CAMPER WILL NOT BE ABLE TO STAY AT CAMP.
IT IS YOUR RESPONBILITY TO COMPLY WITH THE MEDICATION POLICY AND PROCEDURES. IF YOU HAVE ANY QUESTIONS, PLEASE CALL DARLENE LOCKE AT 979.845.6535
Mission Possible additional camper information INSTRUCTIONS: Complete the entire form and return to the Texas 4-H Conference Center. Camper Name _____________________ ____________________________ FIRST
LAST
Parent Name __________________________________ Phone ____________________________________ FIRST
LAST
Emergency Contact: Person to be contacted in case parent or guardian cannot be reached in an emergency: Name ______________________________________ Phone_______________________ Medical Diagnosis: _____________________________________________________________________________ MEDICATIONS are being sent with minor in quantity to meet his/her needs during camp. Please read and comply with Mission Possible Medication Policy and Procedures.
Yes
No
Additional information will be required on Health Statement
GENERAL INFORMATION
Please complete with as much detail as possible. Staff depend on the
information to acquaint himself or herself with the camper and to ensure a positive experience for all. MEDICAL INFORMATION: (check all that apply) _____ dehydrates easily _____ easily constipated _____ frequent loose bowels/stool _____ uses inhaler _____ diabetic _____ uses insulin pump _____ bi-polar _____ medications for anxiety_____ medications for depression _____ seizures Type of seizure: ________________________________________ Frequency ___________________________ Duration _____________________________ ALLERGIES: List all known allergies, including medications, food, insects, etc. __________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Describe reaction to allergies: ___________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ How do you know when camper does not feel well? ____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Operations or Serious Injuries (list along with approximate date). _______________________________ __________________________________________________________________________________ __________________________________________________________________________________ Chronic or Recurring Illness: ___________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
BEHAVIOR MANAGEMENT: (mark an “x” for all that apply) _____ is hyperactive _____ may become homesick _____ likes to be center of attention _____ may use foul language _____ prefers to work alone _____ may become aggressive when upset _____ may be stubborn _____ does not like to be touched _____ may express self physically, i.e. hugs often _____ management strategies that work at home or school: _____ withhold privileges _____ time out _____ redirection _____ other (explain) _______________________________ (what works best for you) IF CAMPER HAS A BEHAVIOR PLAN, PLASE ATTACH A COPY.
DAILY LIVING SKILLS
Please complete with as much detail as possible.
EATING: (mark an “x” for all that apply) _____ no assistance needed _____ difficulty swallowing solids _____ needs Thick-It _____ some assistance needed _____ has a tongue thrust _____ uses a straw _____ total assistance needed _____ needs food blended _____ assist with cutting _____ will provide special utensils _____ difficulty swallowing liquids _____ assist with drinking _____ requires a special diet _____________________________________________ _____ other __________________________________________________________ PERSONAL CARE: (mark an “x” for level of assistance needed) Dressing ___none Bathing ___none Combing Hair ___none Brushing Teeth ___none Toileting ___none Transfering ___none
___some assistance ___some assistance ___some assistance ___some assistance ___some assistance ___some assistance
___total ___total ___total ___total ___total ___total
assistance assistance assistance assistance assistance assistance
Does camper wear dentures? ___ Yes ___No Does camper wear diapers/depends? ___ Yes ___No Does camper use catheters? ___ Yes ___No Type of catheters: ___________________________________________________ MOBILITY: (mark an “x” for all that apply) _____ walks alone _____ walks with assistance _____ walks with crutches/walker _____ uses manual wheelchair _____ uses electric wheelchair _____ other _________________________________________________________
COMMUNICATION AND SENSES COMMUNICATES: (mark an “x” for all that apply) _____ speaks clearly _____ may be difficult to understand _____ uses gestures _____ writes _____ uses communication board _____ uses eyes _____ uses sign language _____ other __________________________________
EYESIGHT: (mark an “x” for all that apply) _____ 20/20 vision _____ some vision _____ blind _____ wears glasses _____ will bring glasses to camp _____ will not bring glasses to camp special instructions: ______________________________________________ HEARING: (mark an “x” for all that apply) _____ normal hearing _____ some hearing _____ deaf _____ wears a hearing aid (left ear) _____ wears a hearing aid (right ear) _____ will not bring aid(s) to camp special instructions: ______________________________________________
SLEEPING/MISCELLANEOUS (mark an “x” for all that apply) Does camper have any special needs at night? (positioning, sleeping, toileting, equipment) (please explain) _________________________________________________________________________________ _________________________________________________________________________________ Does camper sleep through the night? ___ Yes ___No Does camper require a nap during the day? ___ Yes ___No Does camper have any known fears? ___ Yes ___No please list _______________________________________________________ SPECIAL REQUESTS: Indicate if camper wishes to be in the same cabin with a specific camper. ___ Yes ___No (camper name) ________________________ Indicate if camper may have privacy or space issues in dormitory. ___ Yes ___No Describe ____________________________________________________________ Please understand that we will make every effort to accommodate these requests.
CAMP ACTIVITIES (mark an “x” for all that apply) RESTRICTIONS WHILE AT CAMP: ____________________________________________________ _________________________________________________________________________________ SWIMMING: (mark an “x” for all that apply) _____ swims well _____ needs flotation devices _____ does not know how to swim _____ fear of water _____ will provide floats _____ limited swimming skills _____ shallow end only _____ cannot get head wet _____ has tubes in ears _____ NO SWIMMING _____ Special instructions: _______________________________________________ CHALLENGE (ROPES) COURSE: (mark an “x” for all that apply) The Challenge (Ropes) Course is a series of elements that range from six (6) inches above ground to three (3) feet above the ground. One element (the climbing tower) is twenty-five (25) feet above the ground. Each participant must wear safety equipment (furnished by certified instructors) and is secured by safety cables. Two counselors assist them at all times. _____ has done this before _____ is afraid of heights _____ has never done _____ needs some assistance _____ no assistance _____ NO ROPES ACTIVITIES _____ Special instructions: ______________________________________________
USE THIS SPACE TO TELL US ANYTHING YOU WOULD LIKE TO SHARE ABOUT YOUR CAMPER THAT WOULD HELP US TO PROVIDE A POSITIVE CAMP EXPERIENCE. Answering ‘YES’ to any question does not disqualify your child, it only helps us positively manage his/her behavior. Stress triggers: ______________________________________________________ ___________________________________________________________________ Communication style and system: __________________________________________ ___________________________________________________________________ Social interactions: ____________________________________________________ ___________________________________________________________________ Does camper have issues with ‘personal space’: ________________________________ ___________________________________________________________________ Has camper experienced any traumatic event that could affect his/her behavior while at camp? _____________________________________________________________ ___________________________________________________________________ Repetitive behaviors and special interests: __________________________________ ___________________________________________________________________ Does camper have any history of aggressive behavior? (hitting, biting, shoving, pulling hair): ______________________________________________________________ ___________________________________________________________________ Has the camper ever reacted violently towards another individual: _________________ ___________________________________________________________________ Behavior management techniques used: _____________________________________ ___________________________________________________________________ Calming activities: _____________________________________________________ ___________________________________________________________________ Motivators: __________________________________________________________ ___________________________________________________________________ Typical morning routine: _________________________________________________ ___________________________________________________________________ Typical bedtime routine: ________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Other: _____________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
CONSENT TO PARTICIPATE IN MISSION POSSIBLE This camper health & consent form is correct and complete to the best of my knowledge and the person herein described has permission to engage in all camp activities except as noted. Name of Family Physician _______________________________________ Medical Insurance Carrier: ______________________________________ Policy Number: ____________________ Are immunizations current? ____ yes _____ no Date of last Tetanus immunization: __________________________
Signature of responsible parent/guardian: ___________________________________ Printed name
__________________ date
___________________________________ Signature PHYSICIANS AUTHORIZATION I have examined the person herein described and reviewed his/her health history. It is my opinion he/she is able to engage in all camp activities, except as stated. __________________________________ __________________________________ __________________________________ __________________________________ __________________________________
signature of examining physician printed name phone number, including area code mailing address date of exam
Please note, in addition to completing this application, Mission Possible participants must also complete the Health Statement. There may be duplication of information requested in some areas. But, it is in the best interest of the youth participant.
