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To register, fill out the application, print, sign, and return by no later than Monday, May 13, 2024

Employment 4 Life is a week-long employment experience. This is where campers will test their skills for living independently, getting a job, and planning recreation.
At the camp we will have trained staff that are comfortable with a wide variety of disabilities and communication styles. We prepare hard to make sure each camper has an amazing experience.
We DO expect campers to be independent with toileting. We can offer verbal and visual prompts to use the bathroom, but we do not train our staff to help with wiping or change diapers. Campers who are routinely aggressive or engage in frequent dangerous behavior (such as running away or eating non-food items) may not be a good fit for our program. Our lengthy application asks for tons of information about your camper so that our counselors can help him or her to be successful at camp. If you have questions, we are happy to discuss your camper in more detail before you apply.
All information provided will be kept confidential. Unfortunately, we cannot take everyone that applies due to space and staff ratio. We do expect campers to be independent with toileting, and campers who are routinely aggressive or engage in frequent dangerous behaviors may not be a good fit for our program. Additionally, we may schedule in-person interviews to assure we can meet all camper needs.

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* 1. Camper's First Name?

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* 2. Camper's last name?

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* 3. Has Camper attended a Camp event before?

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* 4. Camper Date of Birth

Date

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* 5. Camper Sex

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* 6. Address

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* 7. Transition Services - Do you have the following Services?

  Options
Michigan Rehab Service
Community Mental Health PCP
Bridge Card
Resume'
Job Portfolio
Social Security Check
Drivers License
State ID
Signed up for Selective Service (Men)
Have you ever had a paid job?
Any job experience?
Do you want employment in the near future?
Business Casual Clothing

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* 8. Last School Attended

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* 9. Disability

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* 10. Does Camper have any dietary restrictions?

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* 11. Please list all of Camper's allergies (food, medication, etc.) and the reaction.

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* 12. Please list all medications Camper takes and reason for taking.

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* 13. Please describe any general health conditions Camper has.

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* 14. Please describe any physical limitations Camper has.

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* 15. Does limitation require specific accommodations?  Please describe.

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* 16. In the following section, please check all statements that describe your Camper. Please answer thoroughly. This information will help us be prepared with the appropriate support(s) for your Camper.

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Uses complete sentences to communicate
Uses 2-3 word phrases to communicate wants and needs
Uses single words to communicate
Uses physical items they want/need to communicate
Uses pictures to communicate
Camper can read basic safety signs
Camper can read picture supported text
Camper can read a daily schedule
Camper can read independently
Can Camper ask for help
Does Camper communicate illness or pain?
Does Camper communicate likes/dislikes?
Has poor appetite
Camper uses toilet independently
Camper needs to be prompted to go
Camper needs some assistance using the toilet
Camper needs complete supervision in restroom
Camper swims well
Camper cannot swim, must remain in the shallow end of the pool
Camper needs to wear lifejacket in the pool at all times (Camper must provide)
Camper willingly takes showers
Camper is independent with dressing/undressing routines
Camper has privacy issues
Camper needs a lot of assistance undressing/dressing routines

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* 17. Does Camper recognize safe/unsafe situations and demonstrate appropriate fear of unsafe situations?  

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* 18. Any additional information to share about communication, self-care, etc.?

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* 19. Behaviors

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Camper hurts self
Camper hurts others
Camper touches others inappropriately
Camper throws things
Camper gets into others personal belongings
Camper wanders away from group
Camper uses inappropriate language
Camper refuses to walk or participate
Camper has difficulty with transitions
Camper argues with adults or peers
Camper acts inappropriate in public

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* 20. Please describe positive behaviors of Camper

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* 21. Please describe any behaviors above or any not listed

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* 22. What else should we know about Camper to make his/her camping experience a great one? The more we know about likes, dislikes, skills, and needs the better we can serve the camper.

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* 23. I give permission to myself or Camper to swim.

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* 24. Emergency Contact

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* 25. Emergency Contact Cell Phone

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* 26. Emergency Contact Home Phone

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* 27. Parent Email

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* 28. Parent Address

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* 29. Parent Phone Number

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* 30. Does someone have guardianship of Camper?

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* 31. If someone is guardian, who is that guardian

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* 32.
Camper/Parent/Legal Guardian Agreement - Disability Network West Michigan

Release and Indemnity Agreement and Acknowledgement of Risk
(Please read this document carefully and sign below.)

This Release and Indemnity Agreement and Acknowledgement of Risk is made and entered by and between the parent(s) or legal guardian(s) or independent Camper before mentioned on this application.

On behalf of the Camper, the parent(s)/legal guardian(s) / or I hereby acknowledge and agree that;

Employment 4 Life Camp is for Campers that may have special needs;

Camp activities may involve a degree of risk of injury which cannot be eliminated and may be inherently dangerous, and the degree of risks may vary depending upon the abilities of the Camper, the activity and its location, whether on property or elsewhere;

I/we have carefully considered the risks, including any additional or unique risks which may arise due to the special needs of my Camper, or other Campers who may attend;

Having considered the risks, I request and consent for my Camper to attend, and to participate and engage in all Camp activities, travel and events, wherever they may be held, and to use the facilities and services of Camp, as well as other facilities utilized for activities of the Camp, and I accept any and all related risks.

Now, therefore, and in consideration of the Camper being permitted to attend at Camp, and for other good and valuable consideration, the sufficiency, adequacy and receipt of which is hereby acknowledged, I hereby agree for myself and my heirs, executors, assigns, wards and the Camper in my care, to release, discharge, hold harmless and indemnify as follows:

I acknowledge, accept and assume all risks which may be involved with the Camper participating in the activities of Camp.

I release, discharge, hold harmless and agree to indemnify Disability Network West Michigan, its members, agents and employees from any and all liability, claims, actions, costs and expenses which may arise from any injury or harm which the Camper may suffer, whether bodily or property, while, or as a result of, attending Camp, and participating in its activities, or using its facilities and services.

I further agree to not file suit, pursue any claim, or participate in any legal action against Disability Network West Michigan, its members, agents and employees.

I understand and agree that by this Agreement and Release I am giving up, among other things, the right to sue Disability Network West Michigan, its members, agents and employees for injuries, damages or losses that may occur. I also understand that this Agreement and Release extends to and binds my heirs, executors, administrators and assigns.

Medical Treatment and Needs:

I hereby authorize Disability Network West Michigan, and its employees, members and agents to render first aid and seek medical treatment and care for the Camper when in their judgment it is reasonable and necessary, and I release Disability Network West Michigan from any and all claim(s) arising now or later from first aid or medical treatment rendered to the Camper.

Before leaving my Camper at the Camp, I have informed the Disability Network West Michigan members of any special medical needs

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