Spring Break Camp Application Client Information Question Title * 1. Client Name: Last First Middle Birthday (mm/dd/yyyy) Age Question Title * 2. Address: Street City/State County Zip Code Question Title * 3. Guardian Information: Guardian Name Relationship to Client Question Title * 4. Guardian Contact Information: Phone Number Cell Phone Email Question Title * 5. Primary Language English Spanish Other (please specify) Question Title * 6. Are you new to Camp Sunnyside? Yes No Question Title * 7. Please mark all activities that are RESTRICTED: Swimming Boating Sensory Room Climbing Wall Outdoor Camping Horseback Riding Fishing Adventure Tree Climbing Basketball Dancing Arts and Crafts Archery Outdoor Cooking/Campfires Volleyball Zip Line No Restricted Activities Question Title * 8. Please explain why these activities are restricted: Question Title * 9. Allergies Please list all food allergies and their reaction Other Non-Food Allergies and Reaction Does your client use an epi pen? Question Title * 10. Do you have a seizure disorder? Yes (please list type, date of last seizure, and medical intervention plan) No Question Title * 11. Emergency Contact #1 Name Relationship Phone Number Question Title * 12. Emergency Contact #2 Name Relationahip Phone Number Question Title * 13. Emergency Contact #3 Name Relationship Phone Number Question Title * 14. Preferred Hospital Question Title * 15. Have you sent in a physical within the last 2 year? Yes No Question Title * 16. Last Tetanus Booster Date (We must know the camper's last tetanus booster date in order to be registered to attend camp) Question Title * 17. By Signing here, you give our healthcare staff the premission to provide routine healthcare, dispense medications, and seek emergency treatments. Application Completed By Date Relationship Electrinic Signature of Legal Guardain Question Title * 18. Photo Consent: I hereby consent that any narratives, depictions, pictures, film, photographs, audio-visual or sound recordings or testimonials of me made by Easter Seals may be used by Easter Seals, and those acting with its permission, for the purpose of illustration, broadcast, or testimonial in connection with any work of Easter Seals and that these materials may be released to the general public. I assign to Easter Seals all of my rights to these materials. All photographs and other media which include your image are the sole property of Easter Seals Iowa. Such photos may be used at various times unless you revoke this photo consent in writing. Any revocation is valid from the date it is received by Easter Seals Iowa and will not apply to photos that have been used prior to the revocation in any publication or other media. I understand that these materials may be published on Easter Seals' network of Web sites and this may disclose my personal and protected health information. To ensure the privacy of any person under age 18, Easter Seals will use only the first name and the location of the Easter Seals organization where a minor receives services. Easter Seals does not need to submit these materials to me for further approval. I understand that these materials may be modified and that Easter Seals may decide not to use them. I acknowledge that the rights described above are granted to Easter Seals on an unlimited basis without any compensation or payment being made for any current or future use. I understand that this authorization is voluntary and that Easter Seals will not condition any treatment or funding to me on the completion of this authorization. I also understand that I may revoke my consent to allow Easter Seals to release my protected health information if the information has not already been disclosed. To revoke my consent, I must notify Easter Seals in writing by sending my revocation to Easter Seals Intake/Marketing Coordinator. I understand and agree that once Easter Seals, and those acting with its permission, disclose my protected health information as contemplated by this release, this information is subject to re-disclosure and may no longer be protected by the Health Insurance Portability and Accountability Act of 1996. Yes - please take and/or use my picture No - please do not take and/or use my picture Question Title * 19. I fully understand the contents of this release and authorization Electronic Signature of Legal Guardian/Representative Date Signed Relationship to Client Question Title * 20. Waiver of Liability: With the understanding that Easter Seals Iowa (hereafter known as ESI) will make reasonable efforts to prevent accidents, injuries, or other hishaps, I acknowledge the following:- the undersigned, individually or as a parent or natural guardian, in partial recognition of services rendered claims, demands, or actions, causes of action or suits of whatsoever kind or nature for damages sustained by the normal client or accruing to the undersigned in consequence of any accident or occurrence resulting from the use of durable medical equipment and/or participation in any activity or program on ESI and regardless of whether the named client is not on the premises of said ESI< and is engaged in any venture or solely on his or her own behalf. - I give permission for the applicant to attend ESI sponsored programs and to ride in vehicles operated or leased by ESI.- I agree to not send this applicant to an ESI program if he or she has been exposed to contagious disease within three weeks of the starting date of the program and to notify Easter Seals Camping, Recreation, and Respite services immediately if this situation arises.-The applicant has permission to engage in all prescribed activities except those noted by an examining physician or physician assistant and me. In the case of an emergency or ill health, I hereby give permission to the physician selected by ESI to order x-rays, routine test, and treatments. In the event I cannot be reached in an emergency, I hereby give my permission to the physican selected by ESI to hospitalize, secure proper treatment for, to order injections and/or anesthesia and/or surgery for the named participant. - I understand that the participant is responsible for his/her own medical coverage and associated cost.- This release may be revoked in writing except to the extent action has been taken in reliance upon this release Electronic Signature of Guardian/Representative Date Signed Relationship to Client Question Title * 21. Acknowledgement of receipt of the Easter Seals Iowa Incorporated Notice of Privacy Practices:I acknowledge that I have received a copy of the Easter Seals Iowa Incorporated's Notice of Privacy Practices which summarizes the ways my identifiable health information may be used and disclosed by Easter Seals and states my rights with respect to my health information. I understand Easter Seals has the right to revise these information practices and to amend the Notice of Privacy Practices. I have been informed that in the event Easter Seals revises its information practices, a revised Notice will be posted at each Easter Seals location and that I may obtain a current Notice of Privacy Practices at any time from Easter Seals State Office or the website at www.eastersealsia.org. Electronic Signature of Legal Guardian/Representative Date Signed Relationship to Client Done
