AuSM Wahode Day Camp 2010 CAMPER PACKET

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					                                              2380 Wycliff Street, Suite 102     ⋅   St. Paul, MN 55114
                        Telephone: 651-647-1083   ⋅   Fax: 651-642-1230   ⋅   Website: www.ausm.org   ⋅   Email: camp @ausm.org




                            AuSM Wahode Day Camp 2010
                                            CAMPER PACKET

                                                  Camp Butwin
                                               945 Butwin Rd.
                                              Eagan, MN 55123

                            Phone: 651-423-1485                  www.campbutwin.org


To the Parents/Guardians of __________________________________________________:
                                           (camper name)

Your camper has been registered for the following Autism Society of Minnesota Wahode Day Camp:

                      Session I       Monday, July 12 – Friday, July 16, 2010
                                       9:15 am – 3:00 pm


Enclosed you will find the Wahode Camper Packet, which includes a map to your camp location. Parents are
responsible for providing the camper’s daily lunch and transportation to and from camp. 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 if the camper is having difficulty participating at the stated staff to camper ratio.

Camp is staffed by Autism Specialists, Counselors and a Music Therapist. Outdoor activities include
swimming in a heated outdoor pool, horseback riding, use of a ropes course and climbing tower, yoga and
adapted recreation group games.

Be sure to apply sunscreen to your camper, send a lunch and beverage daily, and pack a swimsuit and
towel every day for swimming.

Please note updates to the Registration and Cancellation Policies. Keep the AuSM policies (“Parent Pages”)
and a copy of your completed camper packet for your own records. Camper physicals are not required to
attend the Wahode day camps.


DUE: March 31, 2010 at the AuSM Office (“ADMIN” & “CAMPER” FORMS) – 7 PAGES TOTAL
Campers are not officially enrolled in camp until all forms are on file.

       __ Administrative Forms: (“ADMIN” FORMS) – 3 PAGES
                ♦ AuSM Camp Policy Agreement & Photo/Video Tape Permission
                ♦ Release of Liability (Camp Butwin waiver for horses)
                ♦ Camp Fee Statement - Full payment due April 30, 2010

       __ Camper Information Forms: (“CAMPER” FORMS) – 4 PAGES

DUE: Upon Arrival at Wahode Day Camp (“CHECK-IN ” FORM) – 1 PAGE
     Authorization of Medication Administration Form

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

If you have any questions, please call the AuSM Camp Office voice mail at (651)647-1083, x16.




                                                         PARENT - 1                                                  WAHODE1_10.DOC
                                                  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 AuSM office by the designated due date. Parent/guardian will
     be sent a reminder letter for delinquent packets/required information and be given five business days to submit
     paperwork. If not received by the AuSM office within specified timeframe, camper may forfeit spot in camp for the
     season. All parents or responsible persons must provide the camp office with emergency contact information for the
     entire camp session. AuSM cannot be held responsible for lost or delayed mail.

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.   A phone call shall be made by camp staff at least one week prior to camp to identify up-to date-concerns. The staff
     person making the call shall report any concerns to the Camp Director(s).

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

7.   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.




                                                          PARENT - 2                                          WAHODE1_10.DOC
                                          REGISTRATION POLICY
1. To be eligible for camp registration and to attend an AuSM camp, the parent/guardian/camper must be a
   current member of AuSM.

2. Any membership that expires before camp start must be renewed for a camper to attend camp. If not
   renewed prior to camp start, the camper may forfeit their spot in camp.

3. The non-refundable registration deposit must accompany the registration form which is date stamped
   upon receipt.

4. All AuSM camps are filled on a first come, first served basis.

   RESIDENTIAL CAMPS: have a designated registration deadline date. Registrations received by US Mail
   will be accepted at any time up until the specified deadline date. Registrations received by fax, walk-in or
   email will only be accepted at AuSM effective designated non-mail acceptance date.

   DAY CAMPS: do not have a designated registration deadline date. Registration closes when all camper
   spots are filled.

                                         CANCELLATION POLICY
1. If a camp is cancelled due to insufficient numbers of campers, all camp fees and registration deposit will be
   refunded.

2. If the camper cancels more than 30 days before the start of camp, all camp fees will be refunded, less the
   registration deposit .

3. If the camper cancels 30 days or less before of the start of camp, neither camp fees nor registration
   deposit will be refunded.

4. If parent/guardian/camper chooses to leave camp or not attend camp on own volition as of the camp start
   date, neither camp fees nor registration deposit will be refunded.


                                          SPECIAL DIET POLICY
                                         (RESIDENTIAL CAMPS ONLY)
Camp Director (s) or designee must approve special Diet Requests. After AuSM receives a detailed meal plan
from parents/guardians, approval will be provided within 14 days of the start of camp. Parents/guardians must
provide all food for special diets. Meals must be pre-cooked, microwave ready, clearly labeled and individually
packaged in single portions. The Food Service staff are only able to re-heat meals, not cook them. A Special
Diet Request may be denied if the diet exceeds the capabilities of the Food Service Staff. A regular camp
meal plan will be offered as an alternative. The camp’s standard menu plan will be available prior to camp to
help parents/guardians prepare their special diets as closely as possible to the camp’s standard menu. It is
the responsibility of the parents/guardians to send all Special Diet Requests directly to the AuSM camp
office no later than one month prior to the camp start date.


                            CLOTHING & PERSONAL INVENTORY POLICY
All clothing and personal items must be labeled and listed. AuSM will contact parent/guardian regarding items
left at camp to arrange for pick-up within one month of camp end, at which time items will be donated to
charity. AuSM 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.


                                                    PARENT - 3                                     WAHODE1_10.DOC
                                     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 its
original container. The camper’s medication and the Medication Authorization Form must be provided to the
Camp Nurse or designee upon each camper's arrival at camp.


                                         SWIMMER’S ITCH POLICY
                                        (RESIDENTIAL CAMPS ONLY)
While not common, there is a possibility that the camper may get Swimmer’s Itch. Swimmer’s Itch is little red
bumps on the skin caused by tiny bugs that live in the water. The Swimmer’s Itch bug cannot live outside of
the water. The camp does treat the water to help prevent Swimmer’s Itch. Occasionally, especially after a
heavy rain, campers may still get Swimmer’s Itch.

One way to help prevent getting Swimmer’s Itch is to apply a layer of baby oil gel over sun block to exposed
skin. This helps keep the water droplets from collecting on the skin when getting out of the water. Towel
drying immediately after getting out of the water is also important. If there are no water droplets on the skin,
there should be no Swimmer’s Itch.

The little red bumps are itchy, but are usually gone within 7 – 10 days. Taking Benadryl (Diphenhydramine)
orally and/or applying anti-itch creams keep the itching to a minimum. Please remember to send the camper
with baby oil gel, anti-itch cream and Benadryl (if you checked “yes” on the “Authorization for Administration of
Medication” form).


                                            PHONE CALL POLICY
                                     (RESIDENTIAL CAMPS ONLY)
Do not send phone cards with the camper, as camp staff will not be responsible for the cards. Cell phones are
not allowed at camp. Contact AuSM at (651)647-1083 or the camp directly at the number listed on the front of
your packet.

CAMP DISCOVERY: Campers may call home during the week, particularly if doing so helps alleviate camper
anxiety. We encourage campers to call during the hours of 5:30 - 7:30PM, but we can remain flexible based
upon a parent's work schedule. Please discuss this with your camper so that he/she knows when you prefer to
be called. You may also make note of this time in the camper packet. Courage North has a toll-free telephone
that campers may use with permission.

CAMP HAND IN HAND: Making phone calls takes camp staff away from the camper and the activities.
Please understand that if you call camp, it may not be possible for camp staff to return your phone call
because of the scattered site and the highly structured schedule. If there are concerns, we will call you.




                                                     PARENT - 4                                      WAHODE1_10.DOC
                                                   2380 Wycliff Street, Suite 102     ⋅   St. Paul, MN 55114
                             Telephone: 651-647-1083   ⋅   Fax: 651-642-1230   ⋅   Website: www.ausm.org   ⋅   Email: camp @ausm.org




                                         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 Policy
                 Cancellation Policy
      N/A        Special Diet Policy
                 Clothing & Personal Inventory Policy
                 Medication Handling Policy
      N/A        Swimmer’s Itch Policy
      N/A        Phone Call Policy



Signature                                                                          Date




                                         PHOTO/VIDEO TAPE PERMISSION

As part of the camp experience, your child may be photographed or videotaped with others. AuSM may use these
photographs/tapes 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: ________________________________________________________________________




                                                               ADMIN - 1                                                  WAHODE1_10.DOC
                                                2380 Wycliff Street, Suite 102     ⋅   St. Paul, MN 55114
                          Telephone: 651-647-1083   ⋅   Fax: 651-642-1230   ⋅   Website: www.ausm.org   ⋅   Email: camp @ausm.org



                                      The Jewish Community Center
                                    of The Greater St. Paul Area

                                                RELEASE OF LIABILITY

THIS IS A RELEASE OF LIABILITY OF THE Jewish Community Center of the Greater St.
Paul Area and Camp Butwin.


READ THIS RELEASE CAREFULLY BEFORE SIGNING

I                                               the parent / legal guardian of
               (Parent)                                                                                      (Child)

acknowledge that the use, handling and riding of a horse involves a risk of injury to an
individual undertaking such activities, and a horse, irrespective of its training and / or usual
past behavior and characteristics, may act or react unpredictably at times, may jump forward
or sideways, run away, kick, buck, rear up, or bite, among other things. The undersigned
expressly assume such risks and waive any claims that we might have against the Jewish
Community Center of the Greater St. Paul Area and Camp Butwin as a result of physical
injury, property loss or damage incurred in said activities.

We also expressly release forever the Jewish Community Center of the Greater St. Paul
Area and Camp Butwin from all claims, demands, injuries, damages, actions or cause of
actions, and from all acts of active or passive negligence on the part of the Jewish
Community Center of the Greater St. Paul Area and Camp Butwin, its servants, agents, or
employees and expressly agree that the Jewish Community Center of the Greater St. Paul
Area and Camp Butwin shall not be liable for any claims, demands, injuries, damages,
actions or causes of action, whatsoever, as a result of physical injury, property loss or any
other damage arising out of, or in any manner connected with, the use, handling and
riding of a horse or horses at the Jewish Community Center of the Greater St. Paul Area
and Camp Butwin, or the premises where such stable is located.

Please note: This form is required by our insurance carrier. Campers will not be allowed to ride if
this form is not completed and/or changes are made to this document.

Dated:                                         Parent:

Release of Liability Form – Horse
1/2008




                                                            ADMIN - 2                                                  WAHODE1_10.DOC
                                                     2380 Wycliff Street, Suite 102     ⋅   St. Paul, MN 55114
                               Telephone: 651-647-1083   ⋅   Fax: 651-642-1230   ⋅   Website: www.ausm.org    ⋅   Email: camp @ausm.org


                                   WAHODE DAY CAMP FEE STATEMENT 2010

CAMPER’S NAME:                                                                                           SESSION:           ONE

                                             2010 Camp Fee is $525.00
                                      Registration Deposit              -      $100.00
                           Balance Due April 30, 2010                   =      $425.00

Please indicate your Method of Payment:

Check payable to AuSM:               Payment now with enclosed Check #____________
                                     Check will be mailed to AuSM by April 30, 2010

Credit Card:     Charge my credit card (as provided below) in one payment now

                     Name on card:
                     ( Visa                 MasterCard                      Discover)


                     Card #:                                                                   Exp. Date:
Third Party Payer:

        Please submit a request for payment of $___________ to a Third Party Payer.
        I agree to pay, in full, any amount not covered by the Third Party Payer listed below, by April 30, 2010.

                Third Party Payer Name
                Contact Person Name                                                            Title
                Phone #                                                              Fax #
                Address
                City                                                                           State        Zip
                Email


Membership Renewal:
   As stated in the AuSM Camp Registration Policy, if my AuSM membership expires before camp start date, my
    camper may forfeit their spot in camp. To prevent this from occurring, I authorize AuSM to automatically renew my
    membership on the annual renewal due date and charge my credit card (as provided above) accordingly.



Parent Name (please print)

Parent Signature                                                                               Date


**Financial assistance forms may be obtained by calling (651)647-1083 x16 or email to camp@ausm.org


                                                                 ADMIN - 3                                                   WAHODE1_10.DOC
                                               2380 Wycliff Street, Suite 102     ⋅   St. Paul, MN 55114
                         Telephone: 651-647-1083   ⋅   Fax: 651-642-1230   ⋅   Website: www.ausm.org   ⋅   Email: camp @ausm.org


                                        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# _______________________________________




  INSURANCE CO. ____________________________________ INS. NO. _______________________________
  PHYSICIAN’S NAME __________________________________________________________________________
  CLINIC NAME ____________________________________________ CLINIC PHONE                                       _________
  CLINIC ADDRESS                                             ________
  CAMPER'S DOB ________________ AGE (at time of camp) ______ HEIGHT _____ WEIGHT                                       _______
                                                                                  (Please estimate if you do not know)




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




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




        Signature                                                                                            Date

                                                        CAMPER INFO -1                                                WAHODE1_10.DOC
                                               Camper’s Name:    _______________________________

 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 _______________%



                                               CAMPER INFO -2                                WAHODE1_10.DOC
                                               Camper’s Name:   _______________________________

                      SPECIAL MEDICATION/HEALTH INFORMATION
**See “Medication Handling Policy” (PARENT - 4) & “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?




                                               CAMPER INFO -3                                 WAHODE1_10.DOC
                                               Camper’s Name:   _______________________________



                                            CAMPER PHOTO
PLEASE ATTACH A PHOTO OF YOUR CAMPER TO THIS SPACE

OR

EMAIL A CAMPER PHOTO TO CAMP@AUSM.ORG

(all photos will be retained by the AuSM)

      **Even if your camper has been to camp before, this photo helps us put a face to a name**




                                               CAMPER INFO -4                            WAHODE1_10.DOC
                                                       Camper’s Name:      _______________________________

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


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


Allergies: (List ALL types, food, drug, etc.): __________________________________________________

Please include all prescription, non-prescription, and homeopathic medication(s). If camper needs an
emergency medication (i.e., 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.

                                                        CHECK-IN - 1                                             WAHODE1_10.DOC