AuSM CAMPER PACKET

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www.ausm.org
2380 Wycliff Street, #102 St. Paul, MN 55114 t: 651-647-1083 f: 651-642-1230

To the Parents/Guardians of ______________________________________:

Thank you for your interest in the Autism Society of Minnesota’s Wahode Day Camp, August 7 – 11, 2006.
This year’s camp will be held at the Whittier Magnet School. MacPhail Center for Music is the official
sponsor with AuSM for this exciting day camp opportunity. Camp hours are 9:00am – 3:00pm.

Whittier Magnet School
2620 Grand Ave. South
Minneapolis, MN 55408

Staff to camper ratio is 1:2. AuSM reserves the right to request that a caregiver attend camp or that the camper
stop attending camp (with a pro-rated refund) if the camper is having difficulty participating at the stated staff to
camper ratio.

Parents are responsible for providing camper transportation to and from Whittier, as well as their lunch daily.

Camp is staffed by Autism Specialists, Music Therapists, and an Occupational Therapist will team to integrate
music therapy, social interaction, sensory exploration, art, cooking, yoga and movement.

Please find the enclosed Wahode Camper Packet, which includes a map to Whittier Magnet School.

***Please keep all “PARENT” pages for your information***

DUE: July 1, 2006 at the AuSM Office (All AUSM OFFICE FORMS – “ADMIN”, “CAMPER”)
Campers are not officially enrolled in camp until all AUSM OFFICE forms are on file.

__ Administrative Forms: (“ADMIN/AUSM OFFICE” FORMS)
 AuSM Camp Policy Agreement & Photo/Video Tape Permission
st
 Camp Fee Statement - Full payment due July 1 , 2006

__ Camper Information Forms: (“CAMPER/AUSM OFFICE” & “CAMPER/AUSM OFFICE” FORMS)

If you have any questions, please call the AuSM Camp Office voice mail at (651)647-1083, x16 or email
questions to camp@ausm.org. Or you may contact Todd Schwartzberg at MacPhail (612)767-5373.

Thanks again,
Wendy Jeanetta-Wark and Tami Eshult
Camp Co-Directors

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2380 Wycliff Street, #102 St. Paul, MN 55114 t: 651-647-1083 f: 651-642-1230

AuSM CAMPER PACKET
CAMP SERVICE POLICY
The camps of the Autism Society of Minnesota (AuSM) exist to serve children with autism spectrum disorders,
regardless of the severity of their disability. It is our intention to make camp a safe, enjoyable community for all
campers and staff. Therefore, the following policies shall guide all camp operations.

1. Camp programs shall be planned and operated to employ best practices in working with children with
autism spectrum disorders. To meet individual needs, the Camp Director(s) shall adjust staff ratios and
camp sessions, use proactive strategies, use individual communication systems, use sensory
accommodations, and modify program and environment whenever possible.

2. Camper information packets shall be submitted to the office by the designated date. All parents or
responsible persons must provide the camp office with emergency contact information for the entire camp
session.

3. Parent/guardian/residential staff must indicate in writing the proactive strategies used to prevent problems
with maladaptive behaviors. This should include environmental strategies, refocusing strategies, de-
escalation strategies and any other interactive strategies that work. AuSM reserves the right to deny camp
attendance to any camper whose principal behavior management plan relies on the use of physical
restraints or locked time-outs. No persons employed at camp will use physical restraints or locked time-
out as part of behavior management strategies. Any aggressive or self-injurious behaviors that have been
exhibited by the camper in the past three months should be reported in writing.

4. Program planning and staff assignments shall be made based upon the information furnished through the
parent packets and IEP’s if applicable.

5. All camp staff participate in a mandatory training covering all aspects of camp including the use of
proactive behavior management strategies.

6. If, while at camp, an individual camper exhibits extreme out of control behavior, the following will occur:

a) Camp staff shall use emergency procedures to ensure the safety of the individual camper and other
campers. The camp staff shall report the behaviors to the Camp Director(s).
b) The Camp Director(s) shall assemble a team meeting to determine how to adjust the camper’s
program, environment, or staff support.
c) A written plan shall be prepared describing the problem, suggested strategies, and results of
implementing the strategies.
d) If the Camp Director(s) determines that (1) the plan has been implemented, (2) the individual
camper’s behavior poses a threat to the health, safety, and well-being of the camper and /or other
campers, and (3) the camp lacks the staff resources, space, and skill to serve the camper, the Camp
Director(s) shall call the parent or responsible person to take the camper home.
e) The decision to dismiss a camper from camp must be reported to the Executive Director of AuSM
before the action is taken.

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2380 Wycliff Street, #102 St. Paul, MN 55114 t: 651-647-1083 f: 651-642-1230

REGISTRATION / FEE POLICY
1. Wahode Campers are served on a first come, first served basis as applications and registration deposits
are received at the AuSM office.

2. If the camper cancels up to 30 days before the start of camp, all camp fees will be refunded, less the
$100 non-refundable registration deposit.

3. If the camper cancels within 14 days of the start of camp, only half of the camp fee will be refunded,
less the $100 non-refundable registration deposit.

4. If a camper must leave after the start of camp, any refund will be pro-rated, less the $100 non-refundable
registration deposit.

CLOTHING & PERSONAL INVENTORY POLICY
All clothing and personal items must be labeled and listed. We will make every effort to return all clothes and
items, but will assume no responsibility for lost or ruined articles. The suggested list highlights the expected
minimum needs for one week at camp. We suggest you do not send any expensive or sentimental items, as we
are not responsible for lost or damaged items. If the camper is hard on clothing, please adjust the list to fit the
camper's needs. We do not have the necessary staff or laundry facilities to take care of camper's personal
laundry, other than on an emergency basis.

MEDICATION HANDLING POLICY
ALL prescription medications must be in their original containers, clearly marked with the camper's name and
instructions for administration. A camper will not be allowed to stay at camp if his/her medication is not in it's
original container. The camper’s medication and the Medication Authorization Form must be provided to the
Camp Nurse upon each camper's arrival at camp.

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2380 Wycliff Street, #102 St. Paul, MN 55114 t: 651-647-1083 f: 651-642-1230

CAMPER INFORMATION
Every effort is made to insure that each camper has a positive and fun experience at camp. The information you share will
be part of your camper's notebook, which is shared with all camp staff working with your child. Because many of the
staff members may not know your child, it is important that the information you provide be complete, thorough, and
current. Please use the back of forms if more space is needed.

CAMPER'S NAME ____________________________________________ NICKNAME __________________
CAMPER'S ADDRESS _________________________________________________________________________
CITY _______________________________________________ STATE __________ ZIP ________________
COUNTY ______________________________________ MA# _______________________________________

SCHOOL DISTRICT NAME _____________________________________________ DISTRICT # _________
DIRECTOR OF SPECIAL EDUCATION _________________________________ PHONE _______________
ADDRESS ____________________________________________ STATE __________ ZIP _______________

INSURANCE CO. ____________________________________ INS. NO. _______________________________
PHYSICIAN’S NAME __________________________________________________________________________
CLINIC NAME ____________________________________________ CLINIC PHONE
CLINIC ADDRESS ________
CAMPER'S DOB ________________ AGE (at time of camp) ______ HEIGHT __ WEIGHT _______

PARENT/GUARDIAN NAME ___________________________________________________________________
PARENT/GUARDIAN ADDRESS ________________________________________________________________
CITY ___________________________________________________ STATE ___________ ZIP ____________
PHONE #’s (H) ______________________ (W) ________________________ (C) ________________________
OTHER (OUT OF TOWN) _______________________________________________________________

EMERGENCY CONTACT NAME ________________________________________________________________
PHONE #’s (H) ______________________ (W) ________________________ (C) ________________________

Signature Date

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AuSM CAMP POLICY AGREEMENT

I, , have read and understand the following policies provided by AuSM:
(Parent's Name - please print)

**Please initial each line to indicate that you have read and accept each Policy section.

Service Policy
Registration/Fee Policy
Clothing & Personal Inventory Policy
Medication Handling Policy

Signature: ___________________________________________________________ Date: _________________

PHOTO / VIDEO TAPE PERMISSION

As part of the camp experience, your child may be photographed or videotaped with others. These photographs/tapes may
be used by AuSM in certain promotional or educational programs related to camp.

 Yes - AuSM has permission to use such photograph/video tapes of my child for such purposes

--OR--

 No - AuSM does not have permission to use such photograph/video tapes of my child for such purposes

(Camper’s Name)______________________________________________________________

Signature: ___________________________________________________________ Date: _________________

Relationship to Camper: ________________________________________________________________________

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CAMP FEE STATEMENT
All camp fees must be paid by July 1st , 2006 for camper to attend camp
**Complete form and return to AuSM**

Camper’s Name: AuSM #

2006 Camp Fee is $425.00
Registration Deposit - $100.00
Balance Due by May 31, 2006 = $325.00

Select Method of Payment:
 Check payable to AuSM (Check #____________)
 Credit Card ( Visa  Mastercard  Discover)

 Please charge my credit card (as provided below) in one payment:

 Now  Indicate date:

Name on card:

Card #: Exp:

 I agree to pay, in full, any amount not paid to AuSM by the Third Party Payor listed below, by May 31, 2006.

Third Party Payor Name:

Contact Person Name: Title:

Phone Number(s):

Address: State: Zip:

Parent Name (please print):

Parent Signature: Date:

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2380 Wycliff Street, #102 St. Paul, MN 55114 t: 651-647-1083 f: 651-642-1230

COMMUNICATION & PROACTIVE BEHAVIORAL SUPPORT INFORMATION
1. What are some words/gestures/signs/picture symbols that your camper may use that would be helpful for camp
staff to know? (Primary method of communication & used what % of time?)

2. What topics are of particular interest to your camper? What does he/she most like to talk about?

3. What is your camper really good at?

4. Indicate the title that best describes you camper:
 Scientist  Animal/Nature Enthusiast  Sports Fan
 The Reader  Computer Wiz  Meteorologist
 Artist  Game Boy or Girl  Other

5. What specific things might trigger stress and/or anxiety for your camper? Please be specific.
 Sounds (type)_______________________________________________________
 Smells (specific)_____________________________________________________
 Visual _____________________________________________________________
 Motor/Movement____________________________________________________
 Touch/Tactile________________________________________________________
 Other_______________________________________________________________

6. Does your camper react to stress/anxiety in any of the following ways? (Check all that apply)
Communicative Behavior Rarely Often
 Runs Away
 Fights
 Withdraws
 Becomes Aggressive
 Other

7. Please list strategies/activities/routines that help decrease stress or are calming.

8. Does your camper’s school behavior plan utilize locked time out or physical restraint?

9. Please check the setting that best describes your child's school experience and estimated percentage per day:

 Home school ______%  Part-time inclusion ______%  One-on-one aide ______%
 Special school ______%  Resource room ______%  Individual space ______%
 Full inclusion ______%  Separate classroom ______%  Other _______________%

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SPECIAL MEDICATION/HEALTH INFORMATION
**See “Medication Handling Policy” (PARENT - 2) & “Authorization of Medication Administration” form (CHECK-IN - 1)**

1. Does your camper take any medication? If so, please complete the “Authorization of Medication Administration”
form and include reason for medication.
 Are there special ways your camper takes the medicine (i.e. a special spoon or mixture)? Please be
specific and bring any special items your camper may need.

 Will camp staff need to administer this medication during the camp session? Yes/No (please circle)

 You are responsible to provide staff with any updates or changes on the first day of camp.

2. Does your camper have any special health problems (allergies to food, medications, lotions, etc.)? Please explain.

3. Does your camper experience seizures? If so, please explain type and frequency, and describe a typical seizure
and what happens afterwards.

4. Is there any other information regarding your camper's health that you would like us to know about?

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CAMPER PHOTO
PLEASE ATTACH A PHOTO OF YOUR CAMPER TO THIS SPACE (all photos will be retained by the AuSM)

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Authorization of Medication Administration
***Send a copy with Camper Questionnaire. Bring original to camp for Nurse.***

Name of Camper:________________________________________________ D.O.B._________________

Please include all prescription, non-prescription, and homeopathic medication(s). If camper needs an
emergency medication (such as an inhaler for asthma or EPI-pen for bee stings), please send two.

Medical Condition Medication Strength Dose Time Route Possible Side Effects
1.
2.
3.
4.
5.
6.
7.
8.

Permission to administer, as needed, to be determined by Camp Nurse.
If you check yes, please pack with the other medication listed above for your camper.

Medication Yes No
Diphenhydramine / Benadryl
Acetaminophen / Tylenol
Ibuprofen / Motrin

___________________________________ ____________________________________
Print or Type Name of Physician/Licensed Prescriber Physician's/Licensed Prescriber's Signature

______________________________________________ _________________________
Clinic Name Date

______________________________________________ _________________________
Clinic Phone Number

______________________________________________ _________________________
Clinic Address Emergency Number

Parent / Guardian Authorization
1. I request the above medication(s) be given at Camp as ordered by this Camper's physician/licensed prescriber.
2. I release Camp personnel from liability in the event adverse reactions result from taking the medication(s).
3. I give permission for the medication(s) to be given by designated personnel as delegated by the Camp Nurse.

______________________________________________ _________________________
Parent / Guardian Signature Date Relationship to Camper

NOTE: Medication is to be supplied in the original/prescription bottle

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