All-Star Adventure Program Summer 2016

Transcription

1 Community- Faith-Business All-Star Adventure Program Summer 2016 Child s Name: Gender: M First Name Last Name please circle one Date of Birth: / / Ethnicity: Sexual Orientation: Custody Status: Parent/s: Legal Guardian: DCF: Primary Caretaker: First Name: Last Name: Address: City: Zip Code: Home Phone: Work Phone: Cell Phone: Primary Caretaker: First Name: Last Name: Address: City: Zip Code: Home Phone: Work Phone: Cell Phone: F EMERGENCY CONTACTS (Other than Parents/Legal Guardians) 1) Name: _ 2) Name: Relationship: Relationship: Home Phone/Cell Home Phone/Cell Work Phone: Work Phone: 860 or 203 School Name/Grade: COLLATERAL CONTACTS School Counselor: Therapist/In home work: Probation Officer: P.O. Box 664, 15 Thatcher Road, North Grosvenordale, CT phone fax website: TEEG is a 501c3 charitable organization.

2 Summer ASAP Program Information This session runs Monday, Tuesday, Thursday and Friday June 20 th through August 12 th. Wednesday s are reserved for staff meeting and clinical supervision. Transportation will be provided daily, pick-up will take place between 8 and 9am and drop-off between 3 and 4pm. Before the child may start the program, ALL paperwork (including doctor s note and a copy of the insurance cards) must be completed and returned to program director Colin Whiston at TEEG. CHILD AGREEMENT I agree to participate in program activities and to cooperate fully with my counselor and other staff members who are responsible for my health and safety while I am at the All Star Adventure Program. I further agree that I will respect all of my peers and all TEEG property. I have received and carefully read the TEEG All-Star Adventure Program Client and Family Handbook provided to me and understand the expectations placed on me and my family while I am in the program. Child Signature: Date: Parent/Guardian Signature: Date: FIELD TRIP PERMISSION AND WAIVER As the parent/legal guardian of, I give permission for Camper name Camper name to take part in any field trips and related activities organized by the. I specifically consent to my child s participation, and I hereby waive any and all claims against TEEG, its employees, agents, and assigns for any injury or harm in connection with my child s participation in a field trip. I release TEEG s Clinical programs of all liability of injury, death, or damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program including but not limited to transportation, and hold harmless any TEEG staff or representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined. Parent/Guardian Name Parent/Guardian Signature Date PHOTOGRAPH PERMISSION AND WAIVER I give permission to allow TEEG s All Star Adventure Program to take photographs of my child and to use photos of my child in publicity materials (newsletters, press releases, flyers, etc.) Parent/Guardian Name Parent/Guardian Signature Date

3 TRANSPORTATION INFORMATION I hereby acknowledge that my child will be transported by TEEG staff or those representing TEEG while in a clinical program. I give the staff permission to travel with my child within Connecticut and the neighboring states Rhode Island and Massachusetts and understand that for any trips beyond these states I will be asked to sign a permission slip giving permission to the mentor and my child to travel to the referenced state. 3 Parent/Guardian Name Parent/Guardian Signature Date Any other information TEEG needs to know while transporting your children (car seat, etc.) As the parent/legal guardian of I give permission for Participant s name to be dropped off (circle one) with/without a daily adult signature by the Participant s Name person at the drop off location accepting the child. Parent/Guardian Name Parent/Guardian Signature Date

4 HEALTH HISTORY ALLERGIES TO MEDICATIONS: None / List all: FOOD ALLERGIES: None / List all: Measles Asthma Rheumatic Fever Bed Wetter Mumps Heart Condition Seasonal Allergies Convulsions/Seizures Chicken Pox ADD/ADHD Behavior Problems Learning Disabilities 4 Medications the Child takes: Details of Conditions Checked Above: Operations or serious injuries (give dates): Chronic or recurring illnesses: Other diseases/conditions: Parent/Guardian Authorization: To my knowledge my child has not physical limitations that would prevent him/her from participating in any activity. Parent/Guardian Signature: Date: I affirm that this health history is correct and that the child has permission to engage in all program activities, except as noted by me or the physician. I give the staff permission to provide routine healthcare and seek emergency medical treatment when necessary. Parent/Guardian Signature: Date: INSURANCE COVERAGE: Attach copy of medical insurance card No Insurance Company: ID# Subscriber s Name: Group # Medicaid #

5 Summer 2016 Over-the-Counter Medications Permission is needed for the following over the counter medications to be administered to applicant if deemed necessary by the staff. Please note that the name brand or its generic equivalent may be used. Dosages will be administered according to the directions on the original container unless a physician directs otherwise. Please cross out any medications that are not to be administered. If preferred, alternate over-the-counter medications may be sent with the child. All medications must be sent in the original containers with the dosage instructions provided. 5 Condition Treated Burns Chapped/Dry Lips Dry Eyes Emergency Allergy Eye Wash Headache Insect bite Poison Ivy Rash Seasonal allergies Skin Break Sore throat Other Medication Used Burn Gel, Burn Cream Chapstick, Vaseline Moisturizing eye drops, saline solution Epipen, Benadryl Saline Solution, Eye Wash Tylenol, Ibuprofen Medicaine, Afterbite, Afterbite Jr. Caladryl, calagel, calamine lotion Hydrocortisone cream, benadryl cream Sudafed, Benadryl Bacitracin, triple antibiotic cream/ointment, antiseptic, isopropyl alcohol, hydrogen peroxide Throat lozenge Bug Repellent, Sunscreen AUTHORIZATION FOR ADMINISTRATION OF THE ABOVE MEDICATION/S I request that medication be administered to my child as described and directed above. Name of Parent/Guardian Authorizing Administration of Medication Relationship to child: Mother Father Guardian/Other explain Address Phone Number Alternate Number: Signature of Parent/Guardian Date

6 PHYSICIAN S FORM To be filled out by the child s physician or dentist 6 IMMUNIZATION HISTORY: Include all dates of basic immunizations and most recent boosters. (A vaccination history record may be attached, but must include all information) DPT 1 st 2 nd 3 rd Tetanus Booster Oral Polio 1 st 2 nd 3 rd Booster HEP B 1 st 2 nd 3 rd Booster MEASLES 1 st 2 nd Booster PPD Dare (Optional) VACCINE/MMR (LIVE) Other Date Other Date Other : HEENT Mental Health Heart Lungs Abdomen Genitourinary Extremities Posture / Spine Metabolic PHYSICAL EXAMINATION Satisfactory Not Satisfactory Not Examined Details Additional Health Information: Applicant is under the care of physician for the following conditions: Regularly Taken Medications: General Appraisal of Patient: Restrictions for the program: None Other: I have examined the person herein described and reviewed the health history. It is my opinion that this child is physically able to participate in the All-Star Adventure Program activities except as noted above. I attest that this child has had a physical within the last 2 years. Last Exam Date: / / (Must be within 2 years of program) Prescriber s Name: License #: Prescriber s Address City, State: Phone: Fax: PRESCRIBER S SIGNATURE: Date

7 Summer 2016 AUTHORIZATION FOR ADMINISTRATION OF MEDICATION To be filled out by the child s physician or dentist (Please disregard this page if no medications are being taken on a routine basis) Parents/Guardians requesting medication administration to their child from staff shall provide the program with appropriate written authorization(s) and the medication before any medications are administered. Medications must be in the original container and labeled with child s name, name of medication, directions for medication s administration, and date of the prescription. AUTHORIZED PRESCRIBER OR DENTISTS ORDER (Physician, Dentist, Physician Assistant, Advanced Practice Registered Nurse): Name of Child Date of Birth Today s Date Known Food or Drug: Allergies Yes No Reactions to? Yes No Interactions with? Yes No If yes to any of the above, please explain 7 Prescription #1 Prescription #2 Medication Name Dosage Method Time of Administration Controlled Drug? Yes No Yes No Specific Instructions for Medication Administration Relevant Side Effect of Medication Plan of Management for Side Effects

8 Diagnosis: Mental Health 8 Treatment: Any concerns with SI/HI/SIB: Symptom Past Present Abuse/Neglect Aggression towards other verbally/physically Destruction of property Fire Setting Stealing Running Away Sexualized Behaviors Truancy Abuse towards animals

9 9 Interpersonal Relationships Family Relationships: Social Relationships: Recreation Activities involved in/would like to be: Likes/Dislikes:

10 10 Substance Abuse Use/Concerns Cigarettes Alcohol Marijuana Opiates Cocaine/Crack Heroin LSD Other: Everyday 4-5 times a week 2-3 times a week Occasionally Never Any other additional information/concerns:

11 11 *Areas to be completed with the client and staff 1:1 during intake* Interpersonal Relationships Family Relationships: Social Relationships: (Any concerns with being bullied or bullying) Self: What makes you upset? How does your behavior look for others? What helps you calm down:

12 Recreation 12 Activities involved in/would like to be: Likes/Dislikes: Substance Abuse Use/Concerns Cigarettes Alcohol Marijuana Opiates Cocaine/Crack Heroin LSD Other: Everyday 4-5 times a week 2-3 times a week Occasionally Never Any other additional information/concerns: Staff signature/date Staff signature/date