Spofford SCAMPS 2013 Application
Child's Name: __________________________________ DOB: ___/___/___ Gender: _____ School: ________________________________________ 2012-2013 Grade Level: K 1 2 3 4 5 6 7 School District: _________________________________
One Session: June 3rd- July 26th
Home Address: ____________________________________ City, State, & Zip: ______________________ Work Phone: ______________ Cell Phone: ______________ Home Phone: ______________
Father/Guardian Name: _________________________ Employer: ______________________________ Mother/Guardian Name: _________________________ Employer: ______________________________ Please list all individuals other than the parents/guardians who are authorized to pick up the child from camp. If individuals are not listed on your child's application, staff will not release your child to them: Name: ___________________________________
Relationship to child: _______________________
Name: ___________________________________
Relationship to child: _______________________
Emergency Contact Name: _________________________________________________________________ Work Phone: ______________ Cell Phone: ______________ Home Phone: ______________ Child's Strengths & Interests: _______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Current Diagnosis (please check all that apply): Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425
Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439
My child has no current diagnosis Behavioral Concerns: 1.) Please describe any concerning behaviors your child exhibits at home, school, or in the community? _______ __________________________________________________________________________________________ __________________________________________________________________________________________ 2.) What does your child do when he or she is upset? ___________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3.) What types of situations or triggers may cause problems for your child? ______________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4.) What tends to work in calming your child down when he or she is upset? ________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
5.) What types of rewards and/or consequences do you use at home that are successful with your child? __________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425
Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439
6.) Has your child exhibited any physical aggression at home, school or within the community and if so please describe in detail? ____________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Educational Information:
My child participates in regular education classes
My child is currently in a self contained classroom at his/her school
My child currently has an IEP or 504 plan (please attach copy to application)
My child has been suspended or expelled from school in the past 6 months (please describe below)
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Please indicate how you heard about the SCAMPS summer program: ____________________________________
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_________________________________________________________________________________________ Health Concerns/Other Physical Ailments (Physical impairments, conditions, or allergies that may interfere with daily activities): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425
Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439 Consent for SCAMPS staff to administer the following over the counter medications: Comments Acetaminophen _________________________________ Ibuprofen _________________________________ Robitussin DM _________________________________ Cepacol Lozenges/spray _________________________________ Little noses saline drops _________________________________ Imodium AD _________________________________ Stool Softener _________________________________ Milk of Magnesia _________________________________ Calamine Lotion _________________________________ Caladryl Lotion _________________________________ Hydrocortisone cream _________________________________ Benadryl _________________________________ Triple antibiotic ointment YES NO _________________________________ Current Medications: (Please list all prescribed and over-the-counter medications, including inhalers, how long your child been on these medications and any side effects of the medications?) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425
Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439 Financial Information
1. What is the total monthly income for your household? _____________
2. What amount do you feel you can afford to pay toward camp fee $____________
(Please note that payment must be received by Monday of each week in order for your child to attend camp.)
3. Payment plans are available. Would you like to set up a payment plan? YES NO
If yes, please indicate the amount $________ per week that you are able to pay.
I give my permission for SCAMPS staff to contact my child's current teacher and/or mental health
provider. Please indicate the name and contact information for the above stated individuals.
I, the undersigned, attest to the accuracy of the information I have provided. I understand that the information will be kept confidential, in accordance with HIPPA Laws and shall only be reviewed by those individuals directly involved in the care of my child. ________________________
Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425
Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439 AUTHORIZATION AND RELEASE FOR THE USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PROGRAM PURPOSES
I, the undersigned, do hereby authorize that photographsmay be taken by Spofford of my child for publication in future web and print advertisements and literature for Spofford's SCAMPS Summer Day Camp. The purpose of any publication is to provide awareness of and publicize Spofford's activities, programs, and services. I understand that my child will not be identified by his/her full name. I understand that I am not required to sign this Authorization and, if signed, I may revoke this at any time except to the extent that actions have been taken in reliance on this Authorization. To revoke the Authorization, I may contact the Privacy Officer, PO Box 480227, Kansas City, MO 64148-0227 or by telephone at 816-508-3499. This Authorization expires ________________________ (if I do not provide a date in the blank, this Authorization expires 90 days from the date that I sign this Authorization). I understand that expiration of this Authorization will not cause any publication made as a result of this Authorization to be withdrawn from public circulation at the time of expiration or any time thereafter. I understand that Spofford cannot condition treatment or payment on obtaining this authorization from me unless otherwise permitted by law. I understand that I have the right to inspect or copy the protected health information to be used or disclosed. I understand that Spofford may receive donations from third parties as a result of this Authorization. I understand that if the person or entity that receives the information is not a health care provider that the information may be re-disclosed and is no longer protected by the privacy regulations. I agree that neither my child nor I will receive any financial remuneration for the use of his/her image as described herein. I hereby release and discharge Spofford and its affiliated agencies, their directors, officers, successors, and assignees and their respective employees, representatives, and agents from and against any and all liability, including reasonable attorneys' fees, arising out of the exercise of the rights granted by this authorization. It is further understood and agreed that this waiver and release is to be binding upon myself, the minor child, other family members, and my heirs and assigns. I acknowledge that have read and fully understand this Authorization and Release and am voluntarily signing this Agreement ______________________________________________
Printed Name of Legal Custodian (if child is a minor)
_______________________________________________
Signature of Legal Custodian (if child is a minor)
______________________________________________
Printed Name of Legal Custodian (if child is a minor)
_______________________________________________
Signature of Legal Custodian (if child is a minor)
______________________________________________
Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425
Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439
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