BACK FOR ANOTHER Come and YEAR celebrate

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1 The All Days are Happy Days summer day camp offers a week of fun, learning, and activities for the child with Attention Deficit Hyperactivity Disorder. The University of Tennessee, Boling Center for Developmental Disabilities, sponsors the camp. The camp activities are targeted to the management of Attention Deficit Hyperactivity Disorder behaviors such as: inattention, impulsivity and hyperactivity. The camp promotes opportunities for children to develop appropriate social skills. A professional team of educators, social workers, medical personnel and students will be on site and serve as group leaders and/or consultants. WHO? WHERE? Children ages 6-11 years St. Columba Retreat Center 4577 Billy Maher Road Memphis, TN WHEN? June 12 16, 2017 COST M-F 8:30-3:30 $ May 1 st $ after May 1st INFORMATION CALL: (901) btate@uthsc.edu BACK FOR ANOTHER Come and YEAR celebrate 10 Years CAMPFIRE of Camp with us in 2012! Camp Fire: A specialty camp designed for 12, 13, and 14 yr. olds. Tweens participating in this camp will get an opportunity to shadow counselors, join in team building exercises and prepare for a possible junior counselor position in the future. Only eight slots available. Campers will be considered on a first come basis. Apply Early Cost: $250.00

2 FOR OFFICE USE ONLY Date Application Received: Fee Paid: UNIVERSITY OF TENNESSEE BOLING CENTER FOR DEVELOPMENTAL DISABILITIES ALL DAYS ARE HAPPY DAYS SUMMER CAMP June :30-3:30 Location: St. Columba Retreat Center Cost: $ prior to May 1 st. $ after May 1 st CAMP FIRE $ Checks payable to the University of Tennessee, Health Science Center RETURN APPLICATIONS TO: UNIVERSITY OF TENNESSEE, BCDD 711 JEFFERSON MEMPHIS, TN ATTN: BELINDA TATE HARDY *Be sure to list address where you receive mail. Also, please call us as soon as possible if your address and/or phone number changes. Camper s : (Last) (First) (Middle) Sex: Birthdate: Age at start of camp: Address: City: State: Zip: Legal Guardian: (Last) (First) (Middle) *Must be available during camp hours by phone Relationship to Camper: Father: Mother: Guardian: Other: BD: Home Address: City: State: Zip: Home Phone: Cell #: Pager: Bus. #: Ext: Employer: Bus. Address: City: State: Zip: Emergency Contact: : (Last) (First) Home Address: City: State: Zip: Home Phone: Cell #: Pager: Bus. #: Ext.: Dept.: Application Submitted for CAMPFIRE: YES (AGES: 12, 13, 14) NO The vision of the BCDD staff is to offer a camp specifically designed for young children with ADHD that will provide an avenue for these children to engage in planned activities which promote increased selfesteem, develop and maintain friendships, understand ADHD and learn appropriate problem-solving behaviors. For information, please call: (901) or (901) or btate@uthsc.edu Website:

3 PERMISSION SLIP Transportation To and From Jewish Community Center DETAILS: From Monday June Scott Shuttle will provide transportation to ST. Columba Retreat and Conference as well as to The Jewish Community Center to swim. Scott Shuttle is a fully insured transportation company. IN ORDER FOR YOUR CHILD TO PARTICIPATE, THIS PERMISSION SLIP MUST BE SIGNED BY THE PARENT OR LEGAL GUARDIAN. TRANSPORTATION/FEES: TRANSPORTATION IS PROVIDED BY SCOTT SHUTTLE AT NO ADDITIONAL COST TO CAMPERS. CAMPERS WILL RETURN TO St. Columba in time for 3:30PM PICK-UP. Campers riding the Shuttle to and from the Boling Center will arrive back at the Center by 4:00PM. q MY CHILD CAN ATTEND THE FIELD TRIPS AS STATED ABOVE AND BE TRANSPORTED BY SCOTT SHUTTLE. q MY CHILD CANNOT BE TRANSPORTED BY SCOTT SHUTTLE AND WILL BE UNABLE TO SWIM q MY CHILD CAN RIDE THE SCOTT SHUTTLE TO AND FROM THE BOLING CENTER. PARENT/LEGAL GUARDIAN S NAME: PARENT/LEGAL GUARDIAN S SIGNATURE: DATE: of Individual VIDEO AND PHOTO CONSENT FORM I consent to participate in and have my child s photo taken and reproduced for use in the All Days are Happy Days video and power point presentations. This production is conducted by or on behalf of the University of Tennessee Boling Center for Developmental Disabilities. I understand that no names will be used in the production or dissemination of the photos. of Legal Guardian (Printed) Date Signature of Legal Guardian

4 University of Tennessee Boling Center for Developmental Disabilities All Days are Happy Days Health Record/Medical Release Form This form must be completed and returned by June 2,2017. Regrettably campers cannot attend camp without the completion of this form by both the parent and physician. Part A To be filled out by parent before presenting to camper s physician. Part B To be filled out by camper s physician. Part A PERSONAL INFORMATION Camper s Last First Birthdate M F Specify camp(s) child will be attending Address City State Zip Home Phone Address Mother s Father s Daytime Phone Daytime Phone Cell Cell Place of employment Place of employment INSURANCE INFORMATION Health Insurance Carrier Plan Number Policy Number Is physician authorization needed? In case of emergency, please notify If neither parent nor guardian is available in an emergency, please contact: Daytime Phone Daytime HEALTH HISTORY (Please check if camper has any allergies, health problems or behavior problems listed below). Allergies Health Problems Behavior Hay Fever Poison Ivy Insect Stings Penicillin Other Drugs Food Other Ear Infections Rheumatic Fever Seizures Diabetes Asthma Concussion Defiant Aggressive Autistic Tantrums Oppositional Anxiety Fears Depression Please list any serious illnesses within the past 3 years (contagious and non-contagious): Please list any operations or serious injuries within the past 3 years (include dates): Has camper been hospitalized within the past 3 years? Does camper have any chronic or recurring illness? Is there anything else in camper s health history that the camp staff should know? List any medication that the camper will be taking while at camp. List any medical appliance (glasses, contact lenses, orthodonture, etc.) that the camper wears. Please list all medications and times of day they are taken. List any specific activities that should be encouraged. List any activities from which the camper should be restricted. IF MEDICATION IS REQUIRED, IT MUST COME IN THE ORIGINAL CONTAINER WITH USAGE/DOSAGE/ INSTRUCTIONS CLEARLY PRINTED ON LABEL. A DOCTOR S NOTE AND PARENT S NOTE MUST ALSO BE SENT. Please describe any behavioral problems your child has, and the management techniques used to address them.

5 CONSENT FOR MEDICAL TREATMENT I do hereby authorize that all of the above information is correct and that my child is fully able to participate in all UT Boling Center for Developmental Disabilities All Days are Happy Days Summer Camp activities without need of individual or specialized attention or medical regimen. I agree to notify UTBCDD of any changes in my child s physical or mental health between the dates of enrollment and the start of the camp as well as during camp. I hereby consent and authorize the administration of all medical treatments advisable or necessary under the judgment of the accredited camp trainers, emergency room physicians or any other clinical physicians with the understanding that I will be notified as soon as possible. If emergency treatment is necessary, I give permission for my child to be brought to the nearest emergency room by ambulance or helicopter for treatment. I authorize staff to release all records necessary for insurance purposes so that my insurance company can be billed for the visit, lab tests and/or x-rays if necessary. If time and circumstances permit, I would prefer my child be taken to his regular hospital. (, Address and Phone Number of Hospital) I will provide all necessary medications and supplies needed by my child. However, if my child requires any additional prescription medications, I give the medical staff permission to obtain these and bill upon my notification. Signature Part B to be completed by camper s physician: of Camper IMMUNIZATION HISTORY Relationship Date of Physician Phone Date of most recent Tetanus Shot (Mandatory) Other immunizations up to date? ڤ Yes ڤ No, explain MEDICAL EXAMINATION Examination must be performed no more than 12 months prior to arrival at camp. Lab if indicated: CODE: S = Satisfactory X = Not Satisfactory (explanation required) O = Not examined General Appearance Height Weight Blood Pressure ENT_ Neck Spine Extremities_ Heart Lungs Skin Abdomen Genitalia Neurological Findings: Allergies (please specify): Please describe any abnormal findings: RECOMMENDATION AND RESTRICTIONS DURING CAMP Special Diet Special Medicine Needed Is Parent Sending Medicine? Strenuous Activity General Appraisal DOCTOR S RELEASE I have examined the person herein described and reviewed his/her health history. It is my opinion that he/she is physically able to engage in all UT Boling Center for Developmental Disabilities All Days are Happy Days Summer Camp activities, except as noted above. Examining Physician (Primary Care Provider) Signature (please print) Telephone Address Date of Examination Zip Code Please mail, fax or completed form to: UT Boling Center for Developmental Disabilities All Days are Happy Days Summer Camp 711 Jefferson Ave. Memphis, TN or FAX: (901) btate@uthsc.edu For more information, call: (901) or (901)