FVSRA Summer Day Camp 2013

8/13/2019 FVSRA Summer Day Camp 2013

http://slidepdf.com/reader/full/fvsra-summer-day-camp-2013 1/16





F V S R A S u m m e r D

a y C a m p

Si x da y ca m ps ha v e b

e en pla nn e d to s er

v e chil dr en a n d you

n g a du l ts wi th s p ecia

l n e e ds, a g es 3

throu gh 3 0. Th e ca m ps a

r e or ga ni z e d by a g e

a n d a bili ty grou ps.

Th e goa ls o f ea ch ca m

p a r e to provi d e

o p por tu ni ti es to e x p eri enc e a va ri e ty

o f r ecr ea tiona l a c t

ivi ti es a n d to a cq u ir

e a n d d ev elo p l eisu r

e skills

whil e en joyin g th e ou

t doors. Ea ch ca m p si t e loca tion ha s a

n in door fa cili ty to

a ssu r e no ca m p ca

nc ella tions

du e to a dv ers e w ea

th er con di tions.

W e ekly th e m es a r e inc

or pora t e d in to ea ch

o f th e ca m ps to o f

f er a va ri e ty o f l eis

u r e a c tivi ti es tha t i

nclu d e

s por ts, ga m es, na tu

r e, dra ma , mu sic, a dv en tu r e a c t

ivi ti es, a r ts a n d cra

f ts, s wi m min g, a g e -a p pro pria t e

fi el d tri ps, visi ts fro

m s p ecia l gu es ts a n d

s p ecia l ev en ts.

Ca m p m e e ts Mon - Thu rs, Ju n e

1 0 -Au g 1. No ca m p Ju ly 4.

Th e su m m er da y ca m

p pro gra m is ba s e d

on th es e fu n da m en t

a ls:

* a n or ga ni

z e d fra m e work

* tra in e d s ta f f

* physica l a n d psycho

lo gica l sa f e ty

* a p pro pria t e s tru c tu

r e

* su p por tiv e r ela tion

shi ps

* o p por tu ni ti es to b e

lon g

* o p por tu ni ti es to ma k e a di f f

er enc e

* o p por tu ni ti es for s

kill bu il din g

* in t e gra tion o f fa m

ily, school a n d co m

mu ni ty

D a y C a m p I n f o r m

a t i o n a l M e e t i n g

Pa r en ts a r e invi t e d t

o a t t en d a n in for ma tiona l m

e e tin g a n d r e gis tra t

ion ni gh t. M e e t th e School S er

vic es

Ma na g er a n d g e t a ll q

u es tions a ns w er e d

firs tha n d.

Tu es, A pril 3 0 fro m

6 - 7: 3 0 PM @ F V S RA

D a y C a m p O p e n H

o u s e

An o p en hou s e is o f f er e d for bo

th pa r en ts a n d ca m

p ers. M e e t th e ca m

p s ta f f who will b e workin g wi th

you r chil d a n d tou r

th e ca m p si t e. Pa r en ts a r e encou

ra g e d to sha r e in fo

r ma tion r e ga r din g a ny

s p ecia l

n e e ds th eir chil d ha

s du rin g this ti m e.

Fri, Ju n e 7 fro m 4 - 6 PM @ ca m p si t

e loca tions

General I nf or ma ti on Re gi s tra ti on I ns truc ti ons Ca mps 4 Sa mpl e Da y 8F or ms

9 -



Ca mp er’s Guid eA d e t a i l e d l i s t o f c a m p in f o r m a t i o n i n c l u d i n g a c a l e n d a r o f e v e n t s , f i e l d t r ip in f o r m a t i o n , g u id e li n e s a n d r e m in d e r s a b o u t c a m p p r o c e d u r e s w i l l b e a v a il a b l e o n l i n e a t w w w . f v s r a .o r g d u r i n g t h e f i r s t w e e k o f J u n e .

Lunc h & SnackE a c h c a m p e r m u s t p r o v i d e t h e i r o w n l a b e le d s n a c k , s a c k l u n c h a n d b e v e r a g e .

Ca mp T -s hir tE a c h c a m p e r w i l l r e c e i v e a D a y C a m p T - s h i r t . T - s h ir t s a r e w o r n o n a l l f i e l d t r ip s .

Disp ensin g of M edica tionI f a c a m p e r n e e d s t o r e c e i v e m e d ic a t i o n d u r i n g c a m p h o u r s , a 3 1 d a y s u p p l y m u s t b e d e l iv e r e d t o t h e F V S R A o f f i c e b y F r i d a y , J u n e 7 . M e d i c a t i o n m u s t b e d e l iv e r e d i n t h e o r i g i n a l p r e s c r ip t i o n b o t t l e , o r i n c l e a r l y m a r k e d c o n t a i n e r s , w h ic h i n c l u d e t h e c a m p e r ’s n a m e , m e d ic a t io n , d o s a g e , a n d t i m e o f d a y t h e m e d ic a t i o n i s t o b e g i v e n t o t h e c a m p e

r . A p a r e n t / g u a r d ia n m u s t c o m p l e t e t h e P e r m is s i o n t o D i s p e n s e M e d ic a t i o n / W a i v e r a n d R e l e a s e o f A l l C l a im s f o r m , s i g n t h e M e d ic a t io n D i s p e n s in g I n f o r m a t i o n f o r m , a n d p r o v i d e w r i t t e n m e d i c a t i o n d i s p e n s i n g in s t r u c t i o n s ( f o r m s a t w w w . f v s r a . o r g u n d e r “ I m p o r t a n t F o r m s ” ) .

S taffin g Ra tioA n a v e r a g e r a t i o o f 1 s t a f f t o e v e r y 3 c a m p e r s i s m a i n t a i n e d a t c a m p s i t e s . T h e r a t io m a y v a r y a c c o r d i n g t o t h e a b il it i e s a n d f u n c t i o n i n g le v e l s o f t h e c a m p e r s . S o m e c a m p e r s m a y r e qu ir e a h ig h e r r a t i o , s u c h a s 1 :1 o r 1 : 2 . B y g r a n t i n g p e r m is s i o n o n t h e s u m m e r d a y c a m p r e g is t r a t io n f o r m f o r F V S R A t o c o n t a c t y o u r c h i l d ’ s t e a c h e r , F V S R A w i l l b e a b le t o g a in v a l u a b l e i n f o r m a t i o n t o b e s t a s s e s s y o u r c h i l d ’ s n e e d s . A ll d a y c a m p s t a f f p a r t i c i p a t e s i n a n e x t e n s i v e o r i e n t a t i o n w h i c h p r e p a r e s t h e m t o m e e t t h e s p e c i f i c n e e d s o f e a c h c a m p e r . F V S R A m a i n t a i n s t h e r i g h t t o d e t e r m in e f i n a l s t a f f i n g r a t i o s .

Pro gra m S taffS i t e d ir e c t o r s a r e t y p i c a l l y c o l le g e g r a d u a t e s o r u p p e r c l a s s m e n in t h e f i e l d o f T h e r a p e u t ic R e c r e a t io n ,S p e c ia l E d u c a t io n o r a r e l a t e d f i e l d . T h e s i t e d ir e c t o r s a r e t h e o n - s i t e s u p e r v i s o r s o f t h e p r o g r a m a n d m u s t h a v e n o n v i o l e n t C r is i s I n t e r v e n t io n T r a in in g ( C P I ) , C P R a n d F i r s t A i d C e r t i f i c a t i o n . D a y c a m p s t a f f e r s a r e t e a c h e r s , t e a c h e r a s s is t a n t s , c o ll e g e g r a d u a t e s , a n d c o l l e g i a n s w o r k in g o n d e g r e e s in T h e r a p e u t i c R e c r e a t i o n , S p e c i a l E d u c a t io n , A d a p t iv e P h y s i c a l E d u c a t i o n o r a r e l a t e d f i e l d , a s w e l l a s m a t u r e h ig h s c h o o l s t u d e n t s . S t a f f m a y w o r k o n e - o n - o n e w it h a p a r t i c i p a n t o r m a y b e r e s p o n s i b l e f o r a g r o u p o f p a r t ic i p a n t s .

2



R e gi s tr a ti o nEa ch Ca m p is limi t

e d to a ma ximu m nu mb e r o f ca m pe rs.

Ea rly re gis tra tion is im por ta n t for a c

ce p ta nce

to ca m p. Re gis tra tions will b e proce ss

e d on a “Firs t Come , Firs t S e rve d ” b a

sis, wi th pre fe re nce give n to

re side n ts o f FVS RA M e mb e r A ge ncie s.

Find forms on pa ge s 9 -1 2.

Ea rly Bird Re gis tra tion: Fri, M a y 10

Re gu la r Re gis tra tion: Fri, M a y 2 4

L a te Re gis tra tion De a dline : Fri, M a y 31

Pl e a s e n o t e, o ur r e gi s tr a ti o n pr o c e s s h a s c h a n g e d t o pr ovi d e a n e ar

l y bir d di s c o u n t .

* Re gis te r b y M a y 10 to re ce ive th e e a rl

y b ird discou n t ( $ 2 5 re du c tion in ca m p fe e ) .

* Re gu la r re gis tra tion de a dline is M a y 2

4.

* Ca m pe rs mu s t re gis te r a t le a s t 10 da

ys prior to s ta r tin g ca m p in orde r to

me e t tra ns por ta tion

ne e ds a nd e nsu re th e ove ra ll sa fe ty a n

d su cce ss o f th e ca m p e x pe rie nce .

* Pa r tici pa n ts ma y e nroll b y th e we

e k , a comb ina tion o f we e k s or a ll e i gh t

we e k s. FVS RA will u se i ts

discre tion to pla ce pa r tici pa n ts b a se d

on th e ir ne e ds a nd FVS RA ’s re sou rce

s.

* Re gis tra tion con firma tion will b e ma ile

d to th e ca m pe r’s h ome . Ple a se no te s

ta tu s on th e con firma tion.

I f pro gra m s ta tu s is o th e r th a n “E ” ( e

nrolle d ) , a n FVS RA s ta f f me mb e r will

ca ll.

* Ple a se no te th a t re side n t ca m pe r

re gis tra tions ta k e priori ty ove r non -re s

ide n t re gis tra tions.Non -

re side n t re gis tra tions will b e proce sse

d a f te r th e M a y 2 4 de a dline .

* Re gis te r ca re fu lly! In th e e ve n t th a t i t

is ne ce ssa ry to a l te r a ca m p re gis tra t

ion a f te r i t h a s b e e n

re ce ive d a t FVS RA , th e re will b e a $1 5 ch a r ge for a ny ch

a n ge to th e re gis tra tion.

S c h ol ar s hi p I n f or m a ti o n

FVS RA h a s sch ola rsh i ps a va ila b le to r

e side n ts wi th fina ncia l limi ta tions. Pa re

n ts or gu a rdia ns in te re s te d

a re re q u ire d to com ple te a sch ola rsh i p

a p plica tion form a nd su b mi t a $ 2 5 non

-re fu nda b le fe e ( a p plie d to

th e pro gra m fe e ) .

Tr a n s p or t a ti o n Tra ns por ta tion - - pr

ovide d b y Firs t S tu de n t - -is Door to Do

or only a nd is a va ila b le to ca m pe rs w

h o re side

wi th in th e b ou nda rie s o f th e Fox Va lle

y, Ge ne va , S t. Ch a rle s, Ba ta via , S u ga r

Grove , Oswe gola nd Pa rk

Dis tric ts a nd th e Villa ge o f S ou th El gin

. Rou te s a re s tre a mline d to k e e p tri ps

a s close to 4 5 minu te s

or le ss a s possib le . Indica te tra ns por t

a tion ch oice on th e re gis tra tion form. T

h e tra ns por ta tion se rvice

will pick u p ca m pe rs a t th e ir h ome , ta k e th e m to ca m p, a nd r

e tu rn th e m to th e ir h ome or a consis te

n t

loca tion de si gna te d b y a pa re n t / gu a rdi

a n.

E arl y bir d r e gi s tr a n t s r e c eiv e

a $ 2 5 di s c o u n t !



3-6 years L il’

Stars

Campers ages 3 to 6 acquire knowledge and play in ways that are significantly different from how older children learn. Staff at Stars organize camp keeping in mind that younger children learn best through direct sensory encounters with their world and by maexploring and experimenting. A consistent schedule is followed from day to day, allowing campers to build trust in the environmeearn a basic sense of time; recognizing what comes first in the day, second, next and last. Summer day camp activities include a coof both passive and active activities in group and individual play settings. Arts and crafts, creative drama, games, music, sports andare all part of the summer day camp experience designed to promote use of--and growth of--cognitive, physical, communication skills. Outings and special guests are planned to enrich community awareness and experience new recreation opportunities.

Dates: Mon-Thurs, June 10-Aug 1. No Camp July 4. Parent Open House: Fri, June 7 from 4-6 PM at camp site

Camp Lil’ StarsIntended for campers ages 3-6 from all FVSRA service areas.

Time: 8:30 AM - 2 PM Location: Pottawatomie Community Center, St. Charles

Swimming Facility: Swanson Pool, St. Charles

4



Camp Rising Stars and Camp Shining Stars allow campers to become more independent while building self-esteem and confidenabilities. Each camper will participate in a diverse set of age-appropriate activities that build skills in developing areas and leisencourage campers to participate in every planned activity using creative motivational tools and lead the group with fun, rewardCampers will fulfill certain rotating responsibilities such as line leaders, lunch clean-up and team leaders. Staff focus on positive reinn a non-competitive environment, coordinating activities that are intrinsically rewarding including: creative arts, dance, movement askill building. A focus on team building and collaborative skills are implemented during team sports and games at the camp site, anhe pool. Special guest and group outings teach overall safety and community awareness.

Dates: Mon-Thurs, June 10-Aug 1. No Camp July 4.

Parent Open House: Fri, June 7 from 4-6 PM at camp site

Camp Rising Starsntended for campers ages 7-12 in the northern FVSRA servicearea (South Elgin, St. Charles, Geneva and Batavia).

Time: 9 AM - 2:30 PM Location: Rotollo Middle School, Batavia Swimming Facility: Sunset Pool, Geneva

Camp Shining StarsIntended for campers ages 7-12 in the southern FVSRAarea (Oswegoland, Sugar Grove and Fox Valley area).

Time: 8:30 AM - 2 PM Location: South Point Center, Oswego Swimming Facility: Oswegoland Aquatic Park, Montgomery

Rising Stars andShining Stars7-12 years



All Stars and Rock

Stars

13-21 year

Camp All Stars and Camp Rock Stars encourage each camper to thrive in a group environment and the community. Camp prenvironment for campers to make friends, lower social anxiety and develop peer relationships. Planned activities challenge campnew things and gain new skills. Campers will play a part in decision making during group choice periods, and will have input on actoutings planned during the course of camp. These activities include: adventure exploration, environmental awareness and the proproblem solving and physical skills. Playing an active role in the community during outings offers a chance to cultivate social skills. Aswimming safety and skill-based games make trips to the pool safe and successful for everyone!

Dates: Mon-Thurs, June 10-Aug 1. No Camp July 4.

Parent Open House: Fri, June 7 from 4-6 PM at camp site

Camp All Starsntended for campers ages 13-21 in the northern FVSRA servicearea (South Elgin, St. Charles, Geneva and Batavia).

Time: 9 AM - 2:30 PM Location: Persinger Center, Geneva Swimming Facility: Sunset Pool, Geneva

Camp Rock StarsIntended for campers ages 13-21 in the southern FVSRAarea (Oswegoland, Sugar Grove and Fox Valley area).

Time: 9 AM - 2:30 PM Location: Fearn Elementary School, North Aurora Swimming Facility: Splash Country, Aurora

6



Beyond the Stars provides purposeful activities, independent living skills and continuing education within the traditional summer setting for campers ages 22 to 30. Campers will develop new skills in cooking and nutrition, money handling, safety and problem sprogramming specifically designed for young adults. Each day offers campers opportunities to socialize through peer interaction; manguage and communication skills while developing new friendships.

Beyond the Stars offers exposure to new leisure and fitness options including sports skills, motor development, aerobic workoutscrafts, music, games and community awareness when visiting FVSRA member agency park and recreation resources. Activities incoutings, special guests and group projects. Campers are sure to stay engaged, active and involved in the community all summer lo

variety of outings and volunteer projects!

Dates: Mon-Thurs, June 10-Aug 1. No Camp July 4. Parent Open House: Fri, June 7 from 4-6 PM at camp site

Camp Beyond the StarsIntended for campers ages 22-30 from all FVSRA service areas.

Time: 9 AM - 2:30 PM Location: The Annex, South Elgin

Swimming Facility: Swanson Pool, St. Charles

22-30 years

Beyond

the Stars



8

S a m pl e D a y

1. A rriva l & fre e ch oice s ta tions

2. A t te nda nce

3. Circle time or cu rre n t e ve n ts

4. L a r ge grou p ga me

5. S ta tions in sma ll grou ps

6. A r ts a nd cra f ts

7. Na tu re 8. S ma ll grou p ga m

e

9. Fi tne ss or gross mo tor a c tivi t y

10. L u nch

11. Pre pa re for pool

1 2. Bu s to pool

1 3. S wim & ga me s

1 4. Bu s to ca m p

1 5. A f te rnoon sna ck s

16. Closin g a c tivi tie s & son gs



Participant Name: __________________________________________________________________Age: ____________________________

Please CIRCLE Camp/Program For Ofce Use ONLY

Camp/Program Name Sch Awd D/C/N Date Ck# Amt B

Lil’ Stars

Rising Stars Shining Stars

All Stars Rock Stars

Beyond the Stars

Please CIRCLE registration choice(s)

TRANSPORTATION IS DOOR TO DOOR. Please provide information regarding pick-up and drop-off location and contact.

Contact Name: _________________________________________ Relationship: ___________________ Phone #: _____________________

Pick-Up Street Address: _________________________________________________________________ City/Zip: _____________________

Drop-Off Street Address: ________________________________________________________________ City/Zip: _____________________

Emergency Contact: ____________________________________ Relationship: ___________________ Phone #: _____________________

PAYMENT — PAYMENT IN FULL IS REQUIRED FOR REGISTRATION. Total Camp Fees Due: ___________________________

IF PAYING BY CREDIT CARD: Visa MasterCard

Credit Card Number: ________________________________________________Expiration Date: __________________________________

Card Holder Signature: ______________________________________________________________________________________________ (REQUIRED for credit card payment)

I grant FVSRA permission to contact participant’s teacher.

School Name: _________________________________________________________________________________________________

Teacher Name: ________________________________________________________________________________________________

Phone #: _______________________________________Email: ________________________________________________________

T-Shirt Size:

NOTE: When registering by FAX, it is mutually understood that the facsimile registration document (including the Waiver & Release of All Claims) shall suand have the same legal ef fect, as the original form.

FVSRA Summer Day Camp 2013 Registration ForBE SURE TO COMPLETE AND SIGN THE OTHER SIDE OF THIS FORM.

PERMISSION TO GATHER ADDITIONAL INFORMATIONI give permission to release information from this registration form and gather additional informat

professionals that would possibly enhance the participant’s recreational involvement. All information wil

confidential.

Participant’s Signature: X _________________________________________________________________________

(18 years or older or Parent/Guardian)

Adult Sm Med LG XLG 2XL 3XL

Child Sm Med LG

O P T I O N A L

Week(s)

Early BirdRegistration

(Deadline 5/10) w/ Trans

Early BirdRegistration

(Deadline 5/10) No Trans

Res/Non-Res

RegularRegistration

(Deadline 5/24) w/ Trans

RegularRegistration

(Deadline 5/24) No Trans

Res/Non-Res

Late RegistrationDeadline

Late Registration(After 5/24)

w/ Trans

Late R(Af

NRes

June 10 - August 1(All 8 weeks)No Camp Wed. July 4

$1998 $998/2535 $2023 $1023/2560 Fri, May 31 $2048 $10

June 10 - June 13 $269 $137/335 $294 $162/360 Fri, May 31 $319 $1

June 17 - June 20 $269 $137/335 $294 $162/360 Fri, June 7 $319 $1

June 24 - June 27 $269 $137/335 $294 $162/360 Fri, June 14 $319 $1

July 1 - July 3No Camp Thurs. July 4

$202 $103/251 $227 $128/276 Fri, June 21 $252 $1

July 8 - July 11 $269 $137/335 $294 $162/360 Fri, June 28 $319 $1

July 15 - July 18 $269 $137/335 $294 $162/360 Fri, July 5 $319 $1

July 22 - July 25 $269 $137/335 $294 $162/360 Fri, July 12 $319 $1

July 29 - August 1 $269 $137/335 $294 $162/360 Fri, July 19 $319 $1



Participant’s Name:___________________________________________________ Date: ________________ (Print)

Participant’s Signature: X __________________________________________________________________ (18 years or older or Parent/Guardian)

Sign & DateWaiver Here

R E Q U I R E D

PARTICIPATION WILL BE DENIED IF THE SIGNATURE OF ADULT PARTICIPANT OR PARENT/GUARDIAN IS NOT ON THIS W

IMPORTANT INFORMATIONhe Fox Valley Special Recreation Association (FVSRA) is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants

he FVSRA continually strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participants’ safety. Howeve

nd parents/guardians of minors registering for this program/activity must recognize that there is an inherent risk of injury when choosing to participate in recreational activiti

ou are solely responsible for determining if you or your minor child/ward are physically fit and/or skilled for the activities contemplated by this agreement. It is always advisabl

he participant is pregnant, disabled in any way, or recently suffered an i llness, injury, or impairment, to consult a physician before undertaking any physical activity.

WARNING OF RISKRecreational activities/programs are intended to challenge and engage the physical, mental, and emotional resources of each participant. Despite careful and proper preparatio

medical advice, conditioning, and equipment, there is still a risk of serious injury when participating in any recreational activity/program. Understandably, not all hazards and

e foreseen. Depending on the activity, participants must understand that certain risks, dangers, and injuries due to inclement weather, slipping, falling, poor skill level or

arelessness, horseplay, unsportsmanlike conduct, premises defects, inadequate or defective equipment, inadequate supervision, instruction or officiating, and all other c

nherent to indoor and outdoor recreational activities/programs exist. Participants must understand that certain risks, dangers, and injuries due to acts of God, inclement wea

alling, equipment failure, failure in supervision, premises defects, and all other circumstances inherent to recreational activities/programs exist. In this regard, it must be rec

s impossible for the FVSRA to guarantee absolute safety.

WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISKPlease read this form carefully and be aware that in signing it and participating in the FVSRA Summer Day Camp 2013 activities, you will be expressly assuming the risk and

nd waiving and releasing all claims for injuries, damages or losses which you or your minor child/ward might sustain as a result of participating in any and all activities conne

ssociated with this program/activity (including transportation services/vehicle operation, when provided).

recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity, and I voluntarily agree to assume that full risk of any and all inju

r loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/w

or accrue to me or my child/ward) as a result of participating in this program/activity against the FVSRA, including its officials, agents, volunteers and employees (hereinafte

eferred as “FVSRA”).

do hereby fully release and forever discharge the FVSRA from any and all claims for injuries, damages, or losses that my minor child/ward or I may have or which may accru

minor child/ward and arising out of, connected with, or in any way associated with this program/activity.

understand the FVSRA may photograph/videotape the events or activity in which I am (or my child/ward is) participating. I give my permission for the FVSRA to use photograph

f me (or my child/ward) for the purpose of promoting the FVSRA and its services/programs. I give my permission with the following understanding: No compensation of any kin

o me (or my child/ward) at this time or in the future for the use of my (or my child/ward’s) likeness. If extenuating circumstances prohibit the use of my (or my child/ward’s) lik

nitial here ________

n the event of an emergency, I understand and authorize FVSRA staff and of ficials to secure from any licensed hospital, physician and/or medical personnel any treatment deem

or immediate care for myself or minor child/ward and agree that I will be responsible for payment of any and all medical services rendered.

have read and fully understand the above Important Information, Warning of Risk, Waiver, and Release of All Claims and Assumption of Risk. If registering a minor participant, I

hat I have read the above to my minor child/ward. If registering by fax, your facsimile signature shall substitute for and have the same legal ef fect as an original form signatur

FVSRA Summer Day Camp 2013 Registration Waiv

Participant Name: __________________________________Age: ________Birthdate: _______________Sex: ________ Ethnicity: ___________(for statistical

Home Address:_________________________________City: ______________________Park District: __________________________ Zip: ____

Primary Home #: _______________________________________________

Father/Guardian Name: _________________________________________Cell #: __________________________Work # _________________

Mother/Guardian Name: ________________________________________Cell #: __________________________Work #: _________________

would like to receive FVSRA program and news updates via email. Email Address (print clearly): ___________________________________

would like to donate to the FVSRFoundation. Please accept my donation of $ _______________

Registration deadline for residents is Friday, May 24. Non-resident registrations will be processed after May 24.

Fox Valley Special Recreation Association

2121 W. Indian Trail • Aurora, IL 60506

Ph: 630.907.1114 • F: 630.907.1116 • www.fvsra.org

Will participant be responsible for self-medication? Yes

Will staff need to administer medication? Yes

Is participant requesting a scholarship? Yes

s this a new address? Yes No

s this a new phone number? Yes No

s this a new participant? Yes No



Annual Information FormForm Valid June 1, 2013 - May 31, 2014

General Information

Medical Information

Participant Information PLEASE COMPLETE EACH SECTION AND PRINT CLEARLY

Name _____________________________________Age __________ Birthdate _________ Sex ___________ Ethnicity _________

Home Address ______________________________City ________________________________State _________ Zip __________

Phone # ___________________________________Park District _________________________Township____________________

School/Work _____________________ Phone# __________________ Teacher/QSP _________________ Phone # _____________Doctor _____________________________________Phone # _____________________

Parent/Guardian Information PRINT CLEARLY

Father’s Name _______________________Cell # ________________ Work # _________________E-mail ____________________

Mother’s Name_______________________Cell # ________________ Work # _________________E-mail ____________________

Emergency Contact

Name ____________________________________________ Relationship _____________________ City _____________________

Home # ________________________________ Cell # ______________________________ Work # _________________________

□ Aging Disorders

□ Arthritis □ Attention Decit Disorder □ Attention Decit Hyperactivity Disorder □ Autism □ Behavior Disorder □ Cerebral Palsy □ Developmental Disability □ Down Syndrome

□ Early Childhood Delays

□ Educable Mental Handicap □ Emotionally Disturbed □ Epilepsy □ Fetal Alchohol Syndrome □ Hearing Impairment □ Learning Disorder □ Mental Illness □ Multiple Sclerosis

□ Multiply Challenged

□ Physical Disability □ Trainable Mental Handicap □ Traumatic Brain Injury □ Sensory Integration Dysfunctio □ Severe Mental Handicap □ Speech & Language Delay □ Visual Impairment □ Other ____________________

Atlanto Axial Instability? If participant has Down Syndrome, does s/he have Atlanto Axial instability diagnosis? □ N/A □

Surgeries? Has participant had any injuries or surgeries in the past year? □ No □ Yes (please describe) ________________________

Wheelchair? □ No □ Yes (manual/electric) ____________________________________________________________________

Does participant need assistance with transfers? □ No □ Yes (gait belt, hoyer, etc.) _________________

Seizures? □ No □ Yes (please attach seizure information sheet)

Allergies? □ No □ Yes (please describe) _____________________________________________________________________________________

Shunts? □ No □ Yes (please describe) _____________________________________________________________________________________

Dietary Needs? □ No □ Yes (please describe: i.e. diabetes, gluten-free, casein-free, G-tube, etc.) __________________________________________

Medication PLEASE LIST ALL MEDICATIONS PARTICIPANT IS TAKING, EVEN IF IT WILL NOT BE DISPENSED DURING PRO

Drug Name ________________________________________ Dosage __________________ Frequency ________________

Drug Name ________________________________________ Dosage __________________ Frequency ________________

Drug Name ________________________________________ Dosage __________________ Frequency ________________Attach sheet with additional medications, if needed.

Check if stated on medication bottle(s): □ Drink plenty of water

□ No direct sunlight

□ Take with food

□ May cause heat sensitivity

□ May cause drowsiness

□ Other __________________

Will participant be responsible for self medication during any program(s)? □ No □ Yes

Will staff need to remind participant to take medication? □ No □ Yes

R E Q U I R E D

Disability Information PLEASE INDICATE PRIMARY DISABILITY WITH A “1” AND SECONDARY WITH A “2.”

for statistic

Communication

NDICATE METHOD(S) OF COMMUNICATION.

Participant communicates... □ verbally □ sign language □ Boardmaker □ other (explain) _______________________

Assisted Devices

NDICATE ASSISTED DEVICE(S) USED.

□ Hearing aid

□ Glasses

□ Orthopedic devices

□ Prosthetic Devices

□ Walker

□ Cane

□ White cane

□ Canadian crutches

□ Other ____



Interaction/Socialization Skills

Behavior

Safety & Recreation

Goals

NDICATE SOCIAL INTERACTION/SOCIALIZATION SKILLS. CHECK THE ANSWER THAT BEST APPLIES.

The participant...

nitiates social interactions □ on his/her own □ with verbal prompting □ avoids social interactions (explain) _________________

___________________________________________________________________________________________________________

Prefers being □ alone □ with peers □ with adults (explain) _____________________________

___________________________________________________________________________________________________________

s most successful in □ large groups □ small groups □ other (explain) __________________________________

___________________________________________________________________________________________________________

Does the participant...

Act out (verbally, physically, etc.) □ No □ Yes (explain)____________________________________________

Respond to specic behavior techniques? □ No □ Yes (explain)____________________________________________

Respond to any incentives to encourage participation? □ No □ Yes (explain)____________________________________________

Need assistance with transitions? □ No □ Yes (explain)____________________________________________

Wander/run from groups? □ No □ Yes (explain)____________________________________________

Please list any sensory issues the participant may have: ____________________________________________________________

___________________________________________________________________________________________________________

NDICATE REASON(S) FOR PARTICIPATION. CHECK ALL THAT APPLY.

□ Physical activity

□ Socialization/friendships

□ Group interaction

□ Skill development

□ Motor development

□ Creativity/self-expression

□ Self-esteem/condence

□ Responsibility

□ Entertainment

□ Other ____________________

Please identify any specic goals parents/guardians would like to see worked on: ______________________________________

___________________________________________________________________________________________________________

FVSRA provides an approximate 1:4 staff to participant ratio.f participant would like to request a closer ratio, please explain why: _________________________________________________

Can participant...Be left alone after a program has ended to wait for a ride? □ No □ YesGet home independently from a program (i.e. walk, take public transportation, etc.)? □ No □ YesSwim? □ No □ Yes

Indicate otation device(s) owned or needed by participant ____________________________________________________

R E Q U I R E D

Signatures I attest that this information is true and accurate to the best of my knowledge and I will notify FVSRA of any cin the above information.

_____________________________________________________________ _________________________

Signature of person completing form Date

Daily Living SkillsFull Moderate Independent Details

What level of assistance does participant need with...

Eating/Drinking (cut food, uses straw, etc.) □ □ □ ____________________________Dressing/Undressing (tying shoes, pulling up swim suit, etc.) □ □ □ ____________________________Toileting (diapers, catheter, wiping, etc.) □ □ □ ____________________________Money handling (monitor for correct change, no concept, etc.) □ □ □ ____________________________Following directions (single step, repetition, visual cues, etc.) □ □ □ ____________________________Safety (crossing street, water safety, etc.) □ □ □ ____________________________Reading (comprehension level, etc.) □ □ □ ____________________________Writing (legibility, words/sentences, etc.) □ □ □ ____________________________Responsibility (keeping track of belongings, etc.) □ □ □ ____________________________



n August 2012 FVSRA teamed with the naonal organizaon Lose the Training Wheels (now iCan Shine) to teach children with sp

needs how to ride a convenonal, two-wheel bike during a week-long camp.

By the end of camp, over 70% of the 24 parcipants were able to ride their own two-wheel bike independently without the need

raining wheels or other adapve equipment.

FVSRA will host a second Lose the Training Wheels bike camp this summer, August 12-16. To learn more about the camp, including

egister, please contact FVSRA bike camp coordinator, Heather Richardson, at (630) 907-1114 x 1212 or [email protected].

Ben was discouraged because he felt too old fortraining wheels. That stopped him from practicing.This program totally got him over the hump!” -Greg Pardue

“Prior to camp, Ian would always choose his scoowas very fearful. Now he is riding his two-wheeleall by himself with a huge smile on his face.”--Jenny Fergus

Lose the Training Wheels Bike Cam



PRSRT ST

US POSTA

PAID

PERMIT NO

FOX VALLE

POSTMASTE

DATED MATER

PLEASE DO NO2121 W. Indian TrailAurora, IL 60506

Phone: (630) 907-1114Fax: (630) 907-1116www.fvsra.org

f you would like to stop receiving this

brochure, please call the FVSRA ofcend ask to be taken off the mailing list.

Lose the Training

Wheels Bike CampThis summer, FVSRA is partnering with iCan Shine to

remove barriers AND training wheels!

Parcipants of the FVSRA Lose the Training Wheels bike

camp will learn to ride a standard two-wheel bike without

the need for training wheels or adapve equipment.

SEE REVERSE FOR DETAILS!

FVSRA Summer Day Camp 2013

Documents