Summer On The Hill 2015 Application

SUMMER ON THE HILL
JULY 12 - JULY 16, 2015
On the campus of Trinity University
San Antonio, Texas
W
Experience independence in a College
Setting, Improve Social Skills and have fun!
Join us in July for a unique opportunity to experience
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independent living, forge new friendships, and have fun.
Summer on the Hill is a residential /college living
experience designed for persons 18 - 26 who:
1) Have Aspergers / AU or mild developmental disabilities
2) Are emotionally and physically well
3) Whose behavior is within acceptable guidelines
Our mission is to further the progress of appropriate
development, and to aid in the improvement of self-esteem,
socialization, and independence in a safe, supportive, and
FUN environment.
 Participants will live on campus in private dorm room with
bathroom shared with suitemate
 In resident student mentors (Trinity Department of
Education student volunteers) who will also facilitate the
structured activities and social interactions
 The staff/participant ratio will be 1/6
 The majority of the activities will be held on campus
 Meals will be provided in the dining hall
Social Skills
Drone session
Nutrition
Games
Yoga
Self Defense
Training sessions for
AU / IDD
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Karaoke
Swimming
Art/Drawing
Social Networking
Field Trip
Goal Writing
Money Management
Interview skills
Ideal candidate for this program will have:
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A desire to be independent
A desire for social interaction
A desire to experience college life
The ability to try new things
The ability to tolerate changes in routine
The ability to accept the differences of others
APPLICATION DEADLINE: June 5, 2015 (Space is Limited)
Cost: $900 (includes meals, housing, programming, but not linens)
Deposit: $100 required with application and will be applied
to the program fee.
Contact: Karen Pumphrey at (210) 490-4300 or email:
kpumphrey@arc-sa.org
Application process will include an applicant interview
 Download application from website: www.arc-sa.org
Sponsored for young adults ages 18-26, by The Arc
of San Antonio and the Education Department of
Trinity University
Summer On The Hill 2015 Application
Application deadline: June 5, 2015
Space is limited
Application Process:
1. Return application and deposit to: SUMMER ON THE HILL
c/o The Arc of San Antonio
13430 West Avenue
San Antonio TX 78216
2. Schedule an interview:
After your application is received, we will contact you to schedule an interview for the prospective participant
Applicant Information
Last Name____________________________________ First Name_____________________________________
Preferred Name_________________________ Address______________________________________________
City_____________________ State ______________ Zip ____________Phone ___________________________
Cell Phone_____________________ Email____________________________ Date of Birth__________________
Primary Diagnosis/Disability____________________________________________________________________
Gender □ Male
□ Female
Adult Shirt Size
□ XS □ S □ M □ L □ XL □ XXL □ XXL
Age ________ Height_________ Weight____________
Parent/Guardian Information
Name_____________________________________ Relation to Student________________________________
Address________________________________________ City____________________ State______________
Zip_______________ Day Phone________________ Evening Phone ________________
Cell Phone______________________
Email ____________________
Emergency Contact Person #1 (This person must be available during session)
Same as Parent/Guardian? □ yes □ no (if no please complete the information below)
Name_____________________________________ Relation to Student____________________________
Address___________________________________ City____________________ State_______________
Zip_______________ Day Phone________________________ Evening Phone ______________________
Cell Phone______________________ Email _______________________
Emergency Contact Person #2 (This person must be available during session)
Name_____________________________________ Relation to Student____________________________
Address___________________________________ City____________________ State _______________
Zip_______________ Day Phone________________________ Evening Phone ______________________
Cell Phone______________________ Email _______________________
The Arc of San Antonio (210) 490-4300
♦ www.arc-sa.org
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Summer On The Hill 2015 Application
Applicant Information (continued)
Please indicate the most recent educational program or residential care environment in which the
applicant has participated. Elaborate as needed to illustrate achievements and/or to identify areas
for improvement. Continue on additional sheets if necessary.
Name of school or program____________________________ Dates/years attended ___________________
If applicant is not currently enrolled in this program, please explain the reason for leaving: __________________
____________________________________________________________________________________
Briefly describe the applicant’s overall experience with this program (strengths, areas for improvement, etc)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Hobbies: ___________________________________________________________________________
Favorite sports and athletics: __________________________________________________________
Level of participation in the sports listed above: __________________________________________
Favorite forms of entertainment: _______________________________________________________
Assistance/Guidance needed for any recreational activities: ________________________________
____________________________________________________________________________________
Please describe the applicant’s reading, listening, and speaking ability: _______________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
If you answer Yes to any of the questions below, please attach an explanation
Has applicant ever been convicted of a crime?
Does the applicant have any pending criminal charges?
Does the applicant have a history of alcohol abuse?
Does the applicant have a history of drug abuse?
The Arc of San Antonio (210) 490-4300
♦ www.arc-sa.org
□ yes
□yes
□yes
□yes
□ no
□no
□no
□no
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Summer On The Hill 2015 Application
Name of Applicant__________________________________________________________
Chronological Age___________________________ Mental Age ______________________
Diabetic
□ Yes (see eating/diet section) □ Insulin Dependent
□ No
Eating/Diet
□ Diabetic Diet
□ Special Diet
□ No help needed at meals
Food must be: □cut □ chopped □mashed □pureed
□ Camper must be fed
□ G – tube
□ Retainer □ Braces □ Dentures
Allergies
□ None □ Yes (list below) □ Epi-Pen
Food:_____________________________________
Medicine:__________________________________
Other:____________________________________
_________________________________________
Seizures
Diagnosis: Please list all (ex. Seizures, asthma, diabetes,
MR, Psychosis, etc)
1.________________________________________
2.________________________________________
3.________________________________________
4.________________________________________
5.________________________________________
Medications
□ No Meds
□ PRN meds only
Medication
Dose
Time
___________________
________
___________________
________
___________________
________
___________________
________
___________________
________
___________________
________
**attach additional sheet if needed**
______
______
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______
______
□ Student can administer medication independently
□ Student needs reminder, but can administer
independently
□ None □ Regularly □ one or two as child
□ currently controlled with medication
□ Student needs help administering medication
Type(s): ____________________________________
Date of Last Seizure: __________________________
Usual Frequency:____________________________
Usual duration of seizures: _______________ minutes
Triggered by: ______________________________
Medication Policy
All prescription medications that the student will
bring should be recorded on this form regardless
of whether or not he/she is administering
independently. All prescription medication must
be in the original prescription container and
should contain only the amount of medication
needed for the duration of Summer on the Hill.
Exceptions to this policy will be considered on an
individual basis.
Ambulation
□ Walks unassisted
Walks using: □ walker □ crutches □ braces □ cane
Wheelchair: □ manual □ electric – bring charger
The Arc of San Antonio (210) 490-4300
♦ www.arc-sa.org
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Communication
Behavior Issues (i.e. stressed induced pacing)
□ No problems
□ Limited but can communicate daily needs
□ Non-verbal Sign Language
□ Yes □ No
Vision
□ Normal □ Glasses/Contacts □ Blind
Triggered by: _______________________________
Suggested Strategies: __________________________
__________________________________________
__________________________________________
Activity Restrictions
□ Yes □ No
□ Normal □ Hard of Hearing □ Aids □ Deaf
Explain: _____________________________________
___________________________________________
Sleep
Heat Tolerance
Hearing
□ No Problems
□ Walks in sleep
Usual bed time:______________
Awakes at: _________________
Personal Hygiene: Brush Teeth, Bathe, Toilet,
Dressing
□ Completely independent
□ Needs some help with: ____________________
_______________________________________
□ Good □ Fair □ Poor
□ Dehydrates Easily
Swimming
Knows How?
□Yes □ No
Ear plugs when swimming:
□ Yes □ No
Wanders
□ Needs total help in all areas
□ Yes □ No □ Occasionally
Additional Instructions
_______________________________________
_______________________________________
_______________________________________
Additional Equipment
□ None □ CPAP/BiPaP □G-tube □Feeding Pump
□ Baclofen Pump □ Other
* Please note that we may not be able to accommodate
G-tubes, feeding pumps, and Baclofen pumps
Please Note:
1. Summer on the Hill is for individuals who are willing to participate in group activities.
2. Summer on the Hill is not appropriate for individuals requiring one-on-one supervision
3. Smoking is not allowed
4. Behaviors that disrupt the normal functioning of Summer on the Hill may result in the individual being dismissed and
no refund of fees will be granted. Such behaviors include, but are not limited to:
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Wandering, running away
Foul language, cursing
Fighting
Tantrums
Refusal or inability to sleep
Incontinence
Sexual acting out
The Arc of San Antonio (210) 490-4300
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♦ www.arc-sa.org
Refusal or inability to eat
Self-injurious behavior
Extreme hypochondria
Throwing objects
Emotional outbursts
Inability to adjust to the Summer on the Hill program
Willful destruction of property
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Summer on the Hill 2015 Application
Name of Applicant__________________________________________________________
Social Security Number______________________ Date of Last Physical Exam____________
Insurance Carrier_____________________________ Group Number__________________
Member Name_____________________________________________________________
Physician______________________________________ Phone _____________________
If Down Syndrome, stable for atlanto-axial subluxation (ASS) □ Yes □ No
Most Recent cervical x-ray for ASS ______________________________________________
Immunization or Date of Illness
Polio ___________ , type___________
Measles_____________
HIB________________
Diptheria/Pertussis/Teatnus_________
Rubella ________________________
Permission to Give Over-The-Counter (OTC) Medications as Needed
Please initial each medication /or generic equivalent that may be administered to your student. Write “No” beside
any medications you do not wish administered. NOTE: You must have a physician’s written orders for any OTC
medications to be given on a regular, scheduled basis.
______ Benadryl
______ Midol
______ Cortaid (skin cream)
______ Emetrol (nausea)
______ Pamprin
______ Pepto- Bismal (upset stomach)
______ Ibuprofen
______ Robitussin (cough)
______ Imodium (diarrhea)
______ Sudafed (congestion)
______ Lanacane
______ Tylenol (acetaminophen)
______ Dulcolax
______ Maalox (heartburn)
______ Other:_________________
Medication Policy
All prescription medications that the student will bring should be recorded on this form
regardless of whether or not he/she is administering independently. All prescription medication
must be in the original prescription container and should contain only the amount of medication
needed for the duration of Summer on the Hill. Exceptions to this policy will be considered on an
individual basis.
The Arc of San Antonio (210) 490-4300
♦ www.arc-sa.org
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Permission/Release Form
Please initial each statement
Medical
______ Permission to Obtain Medical Treatment: I give my consent by signature below for medical
treatment to be obtained for my child/ward/self by a representative of Summer on the Hill in the event I (or my
designee) am unable to.
______ Permission to share Medical Information: I authorize the Summer on the Hill staff and volunteers to
share, without restriction, my camper’s health information and medical records with any person (whether or not
affiliated with Summer on the Hill) as may be reasonably necessary in order to facilitate the care of my camper.
______ Prescription Medication Policy: I affirm that I have read the policy concerning prescription
medication.
______Agreement to Pay for Medical Treatment: I understand that in the event of a medical emergency
affecting my self/child/ward, EMS may be called and my self/child/ ward may undergo hospitalization and/or
treatment. I agree to assume all costs associated with such summoning of emergency medical care, hospitalization,
and treatment, and I hold Summer On The Hill, Directors, and volunteers harmless for any liability, medical or
financial arising from such.
Transport for Off campus Activities and Emergency Transport
_____ Consent/Permission to participate in off campus activities that are specific to the Summer on the
Hill program.
______ Consent/Permission for Summer on the Hill staff to transport the participant to off campus
activities specific to the Summer on the Hill program
______ Consent/Permission for Summer on the Hill staff to transport the participant in the event of a
medical, facility, environmental, or natural disaster.
______ Consent/Permission for Summer on the Hill staff to transport the participant in their
personal vehicle for off campus activities specific to the Summer on the Hill program or in the event of a medical,
facility, environmental, or natural disaster.
The Arc of San Antonio (210) 490-4300
♦ www.arc-sa.org
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Permission/Release Form (continued)
Please initial each statement
Photographs/Videos
______ Consent/Permission for photos or video to be taken during the course of Summer on the Hill for the
purpose of compiling a scrapbook/DVD to share among the staff and students.
______ Consent/Permission for photos or video to be used by Summer on the Hill and The Arc of San
Antonio to portray or promote Summer on the Hill activities.
______ Consent/Permission for the student’s first name to be published in conjunction with photographs or
video. (Last names will not be published.)
Release of Confidential Information
_____ Consent/Permission for the participant’s confidential information to only be shared with the
Summer on the Hill staff for programming purposes only.
I,________________________________________________________ , guarantee that the
information on this application is accurate and hereby release and forever discharge Summer on the
Hill and The Arc of San Antonio, its members, employees, and volunteers from any liability, suit,
claim, or demand, whether for personal injury to myself or members of my family including minor
children, or for property damage which result from any participation in the camping session.
Student Signature_________________________________
Date_____________
Parent/Legal Guardian_____________________________
Date_____________
The Arc of San Antonio (210) 490-4300
♦ www.arc-sa.org
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Summer on the Hill Behavior Checklist
Each applicant will be evaluated on an individual basis. Behaviors listed below that occur with
enough frequency to disrupt the normal functioning of the program may result in dismissed and
no refund of fees will be granted.
Yes
1. Wanders off or runs away
2. Needs help to feed self
3. Throws Objects
4. Emotional Outbursts
5. Tantrums
6. Physically fights with others
7. Injures self
8. Willfully destroys property
9. Bites, Scratches, kicks
10. Foul language/cursing
11. Continually complains of unfounded illness
12. Hallucinates to the point of dysfunction
13. Needs assistance for toileting needs
14. Frequent insubordination
16. Difficulty working with peers
17. Needs one-on-one supervision
18. Demonstrates sexual advances toward others
19. Taunts or bullies others
____
No
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Explanation for any of the above that were answered “yes”: _____________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I understand that students unable to meet behavior criteria will be dismissed from the program and
that program fees will not be refunded.
Applicant’s Signature________________________
Parent/Guardian___________________________
The Arc of San Antonio (210) 490-4300
♦ www.arc-sa.org
Date ____________________
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Summer on the Hill 2015 Application
Payment Information
Cost: $900 (A $100 deposit required with application and will be applied to the program fee. The
deposit will be returned to those that we are unable to accommodate the student this year). Total
fee must be paid no later than July 3, 2015.
Check (make all checks payable to: The Arc of San Antonio)
□ I have enclosed a check in the amount of: $100 deposit
□ I have enclosed a check in the amount of: $800 total fee
Credit Card Information
□ I authorize my credit card to be billed in the amount of: $100 deposit
□ I authorize my credit card to be billed in the amount of: $800 total fee
Please charge my: □ VISA □MasterCard
□ Discover □ American Express
Name as listed on card: ______________________________________________________
Account #:_______________________________ Expiration Date:___________________
Signature:________________________________________________________________
Final Payment is due by July 3, 2015
NO refunds will be made after July 8, 2015
I would like to donate to Summer on the Hill :
□ $10 donation
□ $20 donation
□ $50 donation
□ $100 donation □Other: $_______
Please contact us at (210)490-4300 with any questions
The Arc of San Antonio (210) 490-4300
♦ www.arc-sa.org
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