1 Table of Contents Table of Contents 1 Purpose...2 Demographic Information 3 Participant Information Form..4 Medical Form..5 Group Leader Information..7 Policies and Procedures..10 Itinerary....11 Emergency Information. 12 Emergency Protocol Plan...13 Waiver Form..14 Assumption of Risk Form..15 Memorandum of Understanding...16 Clothing/Equipment List....17 Accident Report Form 18 References..19
2 Purpose of the Trip This trip will be a three day and two night trip to the Cherry Blossom Festival in Washington D.C. to see the monuments, museums, and other tourist attractions. We will be leaving on the morning of April 12 th and coming home the evening of April 14 th. There will be a state bus that I, as the leader, will drive to Washington D.C. and back. Therefore, no one will need to take themselves and we can all travel together. We are going on this trip for the enjoyment for the residents of Sunny View Assisted Living. I want to bring these couples together since there are not many couples at Sunny View. It is my hope that the residents will get to enjoy and experience the Cherry Blossom Festival while also seeing the historic monuments, museums, and buildings of our country s capital.
3 Demographic Information On this trip to our nation s capital, there will be five couples from the assisted living facility. Therefore, there will be an overall amount of ten participants on this trip. The participants are all of age 60-70 and are all in good health for their age. They all will need to take breaks along the trip, but no one is dependent on a cane, walker, power scooter, or wheel chair. Since they are couples going on the trip, there will be five males and five females. All of the participants have been to Washington D.C. before but none of them have been in the last 15 years and many things have changed at the capital. There will be three staff people on this trip, including myself. There will be one female CTRS, one male RN, and one female CNA. Since the older adults are very independent, we do not need more staff people on the trip. The staff who are going on the trip have volunteered their time and are coming in case anything were to go wrong, we would have people there who have worked with all of the older adults before.
4 Participant Information Please fill out the following information below for our records. Thank you. Name Address City State Zip Code Phone Number Home Cell (please circle) E-Mail Emergency Contact Name Relation Address City State Zip Code Phone Number Home Cell (please circle) E-Mail
5 Medical Form Please fill out the information below for our purposes. Thank you. Name Date of Birth Insurance Plan Insurance Number Name on Plan Allergies Long-lasting Conditions (asthma, diabetes, hearing impairment, etc.) Medications you are currently taking or have taken in the last year Injuries you have had in the last year (car accidents, falls, sprains, dislocations, etc.) Injury Date Injury Date Injury Date Do you use any assistive equipment? (cane, walker, wheelchair, hearing aide, etc.) Can you use the restroom by yourself?
6 Can you get dressed by yourself? Have you ever had a stroke? If yes, when? Have you ever had a heart attack? If yes, when? Have you ever broken anything? If yes, when/what? I,, hereby state that I have answered the above information to the fullest honesty. I am aware that holding back any medical information could lead to physical or medical harm to myself on the trip to Washington D.C. if something were to happen. Signature Date
7 Leader Information Ellery Pippin, MS, CTRS Age: 25 Gender: Female Date of Birth: September 14, 1987 Education o Longwood University, Farmville, Virginia, Bachelor of Science Therapeutic Recreation, Graduation: May 2009 o Eastern Carolina University, Greenville, North Carolina, Master s Degree of Science Recreation Therapy Administration, Graduation: December 2010 Certifications and Credentials o CTRS May 2009; worked with older adults in both psychiatric facilities and assisted living facilities, helped run and plan District 12 Regional Special Olympics for two years, worked at a camp for children with disabilities in Roanoke County, Virginia for a summer in college, 11 week internship at Roanoke County Parks and Recreation in Roanoke County, Virginia helping to plan events for children with disabilities, 14 week internship at Roanoke United Methodist Homes helping to plan leisure education and activities for older adults. Other o Has worked with older adults on many occasions, but has experience with all types of clients, friendly to work with, good at dictating jobs, willing to try new things, as the activities coordinator at Sunny View, she sees all residents on a daily basis, so she is familiar.
8 Clark Johnson, RN Age: 30 Gender: Male Date of Birth: August 19, 1982 Education o Radford University, Radford, Virginia, Bachelor of Science Nursing, Graduation: 2004 Certifications and Credentials o Has been a registered nurse for almost 10 years, has worked in many different settings: pediatric unit, emergency room, and currently in assisted living facility, worked for 2 years during college at Roanoke Memorial Hospital in Roanoke, Virginia as a paid intern, worked clinicals all through his four years at Radford University. Other o Wonderful person to work with, he frequently goes on the fishing trips with the men at Sunny View and they all get along very well, very hard worker, graduated with a 3.8 GPA, knows how to help in any medical situation that may occur on the trip. Adalyn Montgomery, CNA Age: 24 Gender: Female Date of Birth: March 6, 1988 Education o Tidewater Community College, Norfolk, Virginia, Certified Nursing Assistant, Graduation: 2008
9 o Longwood University, Farmville, Virginia, Bachelor of Science Nursing, Graduation: still attending Certification and Credentials o Went to the technical school at her high school and continued on to community college to get more experience and a degree, she has worked in a hospital before but did not feel satisfied with her job, has recently gone back to school after talking to some of the staff, she is now attending Longwood University to become a RN. Other o She frequently helps at the socials and loves to paint the older adult women s nails, she is so friendly and gets along incredibly well with the whole staff and the residents, goes through clinicals now while she is in college, has a young daughter at home so she knows how to work with the residents so that everyone has a fair outcome.
10 Policies and Procedures Residents of Sunny View, who are going on this trip, have received this information in their mailboxes two months prior to the trip. They have all signed and returned the forms. 1. Washington D.C. is very busy this time of the year, if we are to do something, we must all agree on it and go together. 2. In order to make traveling safer, we will all ride together in the state bus; there will be no driving up or back separately. 3. In order to go on a trip like this, it is important to always listen to the group leaders. If there is ever a problem, one of them would be more than happy to help. Please contact a group leader at any time on this trip if you should ever need help. 4. We will meet every morning in the hotel lobby, where they will be serving continental breakfast, to eat and talk about the day at 8:30am. If it is ever the case that you will need more time, please contact a group leader. 5. Be courteous of others. If you do not want to go somewhere or do something, we can all discuss it as a group, but please do not say negative things about another person s idea. We are all here for the same learning experience. I agree that I will follow the policies and procedures. If anything were to go wrong, I know to contact a group leader as soon as possible. Signature Date
11 Itinerary Friday, April 12 th Meet in Sunny View s lobby 7:30am Stop for restroom break/breakfast 9:30am Arrive at Courtyard Marriot in Washington D.C. 11:30am Unpack in individual bedrooms and have a short relaxation period 11:45-12:15am Meet in hotel lobby to start our day 12:30am Visit monuments 1:00-2:00pm Get a nice lunch near the monuments 2:15-3:00pm Continue monument tour 3:00-4:30pm Go back to the hotel to rest and get ready for dinner 5:00-6:30pm Meet in the hotel lobby for dinner 7:00pm Eat together in the hotel s restaurant 7:30-9:00pm Everyone off to bed for the big day tomorrow! 9:30pm Saturday, April 13 th Wake up call 7:30am Meet in hotel lobby to have continental breakfast 8:30am Leave the hotel and go to Constitution Ave. for the parade 9:00am Watch the National Cherry Blossom Festival Parade 10:00am-12:00pm Go get lunch at local restaurant once the parade is over 12:30-1:30pm After lunch, go to Smithsonian, National Museum of American History, National Gallery of Art, and Hirshhorn Museum and Sculpture Garden 2:00-5:00pm Go back to the hotel to rest and get ready for dinner 5:30-6:00pm Meet in the hotel lobby for dinner 6:30pm Eat together in a local restaurant 7:00-8:00pm Discuss plans for tomorrow 8:30-9:00pm Everyone off to bed for the big day tomorrow! 9:30pm Sunday, April 14 th Wake up call 7:30am Meet in hotel lobby to have continental breakfast and check out 8:30am Leave the hotel and head over to the Capitol building 9:00am Tour the Capitol building with tour guide 10:00am-12:00pm Grab a quick lunch in a local restaurant 12:30-1:30pm Leave Washington D.C. 2:00pm Stop for a quick bathroom/snack break 3:30pm Arrive back to Sunny View 6:00pm *Times are subject to change. There will be minor setbacks for restroom breaks and sitting all throughout the day. I have added in 15-30 for switching activities for this purpose.
12 Emergency Information Hotel: Marriott Courtyard Address: 900 F Street, NW, Washington, District of Columbia 20004 Telephone: 202-638-4600 Closet Hospital: MedStar Washington Hospital Center Address: 110 Irving St NW, Washington, DC 20010 Telephone: 202-877-7000 Home Agency Contact: Sunny View Assisted Living John Silver, MS Address: 100 Sunny Lane, Roanoke, VA 24018 Telephone: 540-444-5678 Numbers of Participants Family Contact: Johnson (Daughter): 434-120-2233 Armes (Son): 656-234-6789 Smith (Daughter): 540-330-0099 Folley (Nephew): 757-290-1909 Grint (Son): 434-220-1962 Group Leader s Number: Ellery Pippin: 540-874-5003 Clark Johnson: 540-990-3321 Adalyn Montgomery: 540-330-6532
13 Emergency Protocol Plan *If there is an emergency immediately call 911* If anyone is to get hurt the list of people in charge from most to least is as follows: 1. Ellery Pippin 2. Clark Johnson 3. Adalyn Montgomery If a person becomes injured, has a stroke/heart attack, becomes at risk in anyway: 1. Immediately call 911 2. Once 911 has been called, get a group leader 3. Help the at risk person into a position so they cannot hurt themselves or anyone around them 4. Keep calm and await for the emergency team to get there If someone becomes at risk, the Group Leader must: 1. Make sure 911 has been called 2. If 911 has NOT been called, do so immediately 3. Direct group leaders and participants in how to properly position the at risk person 4. Contact participant s family member and explain the situation 5. Wait for emergency team to arrive and follow their instructions Back-Up Group Leader: 1. Once the emergency team has arrived and has taken Ellery, the at risk person, and the spouse to the hospital, the back-up group leader must arrange for everyone to get back to the hotel until the group is back together.
14 Waiver and Release of Liability Form I,, acknowledge that by signing this document, I am releasing the Sunny View Assisted Living community, their staff, members, and directors from liability. I understand that Sunny View Assisted Living is not responsible for any injuries or property damage while on the trip to the Cherry Blossom Festival in Washington D.C. I understand that I have agreed to go on this trip voluntarily and anything that happens on this trip is based off of my own actions. I hereby waive, release, discharge, hold harmless, and promise to indemnify and not to sue the Sunny View Assisted Living community from any and all claims, including claims arising from the Sunny View community s own negligence on the trip to the Cherry Blossom Festival in Washington D.C. Signature Date
15 Assumption of Risk Form I acknowledge that by signing this document, I am releasing Sunny View Assisted Living (Sunny View) and their employees, members, directors, and affiliates from liability. This release form is a contract with legal consequences. I have been advised to read it carefully before signing. Activities covered by this document will be sitting for long periods of time, walking for long periods of time in a congested area, staying overnight in a hotel, going to museums, monuments, and a guided tour of the Capitol building. Although there will be group leaders on this trip who know what they are doing and where they are going, the trip to the Cherry Blossom Festival involves certain risks, including but are not limited to, getting mugged, tripping, falling, getting lost, minor/serious injury, and death. I am aware that this is one of the busiest times of the year in Washington D.C. and that there will be a lot of people. I understand that Sunny View is not responsible for any lost or stolen items. I am aware that I will have to walk for long periods of time and sit for long periods of time. I am aware that we will be going to monuments, museums, and the Capitol building. I understand that there will be self-guided tours and guided tours and that I will have to stay with the group at all times. I represent that I am fully capable of participating on the Sunny View trip to the Cherry Blossom Festival in Washington D.C., without causing harm to others or myself. Therefore, I accept full responsibility for me and for injury, death and loss of personal property. Signature Date
16 Memorandum of Understanding Please initial in all blanks once you have read and understood the paragraph before it. Thank you. 1. I agree to participate in a trip to Washington D.C. to see the Cherry Blossom Festival. I understand the trip is organized for the purposes of providing couples of the Sunny View Assisted Living community with a learning experience to meet one another in the facility, to learn about the capital of the United States of America, and to enjoy the Cherry Blossom Festival. I also agree to pay all sums due in a timely manner when they are due, to advise the group leader immediately of any and all changes including: ability to pay, health, physical conditions, and availability to participate. 2. I acknowledge, understand, and agree that by participating in the trip I am knowingly undertaking travel in a busy, congested area with numerous amounts of people and risk. I further acknowledge, understand, and agree that participation in this trip requires me to sit, stand, and walk for long periods of time each day. a. I understand the physical challenges associated with walking, sitting, and standing for over a 2 hour time span. b. I understand that we will be in an already busy area that will be busier due to the Cherry Blossom Festival. c. I understand that with this much congestion there is a chance of falling, tripping, or being robbed. 3. I further acknowledge, understand, and agree that I fully assume the risks inherent in the trip. I therefore release all claims against Sunny View Assisted Living or the group leader of the trip that I may have arising out of physical injury or death.
17 Equipment/Clothing List Comfortable walking shoes Clothing for 60-ish degree weather (Washington D.C. in April) Rain Ponchos and/or Umbrella Folding lawn chair for the parade All toiletries for staying overnight in a hotel Spending money for restaurants and souvenirs
18 Accident Report Form Please have this form filled out if you are involved in an accident for our records. Thank you. Name Age Address City State Zip Code Mechanism of Injury (how were you injured?) What was the injury? Date/Time of injury Date/Time form filled out Witnesses? Who preformed First Aide/CPR? What is their telephone number? Who filled out this form? What is their telephone number? Other Comments about the accident:
19 References Courtyard Marriott Washington Hotel: http://www.marriott.com/hotels/travel/wascn-courtyardwashington-convention-center/ MedStar Washington Hospital Center : http://www.whcenter.org/ National Cherry Blossom Festival: http://www.nationalcherryblossomfestival.org/2012/10/02/2013parade/