March 14 to March 18, 2016 (9:30AM-3:30PM)
Location:
Please mark off the days:
Monday March 14
Tuesday March 15
Wednesday March 16
Thursday March 17
Friday March 18
Markham
1. PARTICIPANT INFORMATION
Richmond Hill Vaughan
First Name :
Date of Birth (M/D/YYYY):
Address:
Town:
Diagnosis:
Support Ratio: 1:1 1:2 1:3 1:4 1:5
Last Name:
Age:
Postal Code:
Stouffville
Gender: M/F
2. METHOD OF PAYMENT
Cash Cheque (Payable to “Community Living York South”) Master Card Visa
Total Amount $ Camp Fee $ Membership Fee $
Account # Expiry Date:
Cardholder Name: Signature
CLYS membership for 2016:
(Please circle one): Yes No
Account Use Only
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3A. PARENT/GUARDIAN/CAREGIVER (PRIMARY)
Name:
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Email of Parent/ Guardian:
3B. PARENT/GUARDIAN/CAREGIVER
Name:
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Email of Parent/ Guardian:
4. EMERGENCY CONTACT
Name: Phone Number:
Relationship with Participant:
5. NEEDS ASSESSMENT
Mobility:  Ambulatory
 Walker
 Wheelchair
My First Language is: _______________________
 Speak  Understand
Communication Skills:



Verbal
Communicator
Sign Language


Gestures
Other
If English is not your first language do you:
 Speak English and/or
 understand English
Toileting:  Independent
 Supervision
 Assistance
Comments:
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6. MOBILITY PLUS
Mobility Transit #:
Require Hand to Hand Transfer: Yes  No 
7. RECREATIONAL INTERESTS
Participant favorite activities are:
Things Participant would like to learn are:
8. HEALTH
Should staff be made aware of any allergies?: Yes  No 
If Yes: List and Please Explain:
Other Restrictions (i.e. dietary restrictions, seizures etc):
List of Current Medications:
Please Note: Program staff are not trained to deliver medication
9. BEHAVIOUR
Things that will make participant upset are (ie. loud noises, people screaming, transitioning, etc):
Things participant might do when he/she is upset are:
What possible actions can be taken to best support challenging behaviours (ie. Removed from the situation, ignore behaviour, music etc):
What can an emergency situation look like?
What should the emergency plan of action/behavior plan or behavior protocol be?
10. FEARS
Does the participant have any fears? (ie. Buses, swimming, etc):
Can the participant swim? Yes  No  Does he/she requires assistance? Yes  No 
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Payment by cheque: If you are planning to pay by cheque, it must be received and dated at least one week prior to the camp start date.
Cheque Return NSF (Non Sufficient Fund): Any cheques that come back to Community Living
York South (CLYS) as NSF will result in a bank charge fee of $50.
Payment by Credit Card: CLYS accepts Mastercard and Visa. You will need to provide Account holders name, Account number and Expiry date to the staff.
No Refund Policy: there will be NO refunds for any days missed or wanting to withdraw from camp when registered.
Receipts: receipts are issued by the agencies accounts payable and receivable so please notify the coordinator or camp staff that you require one as soon as possible to ensure CLYS can provide this in a timely fashion.
Drop Off and Pick Up: Camp starts each day at 9:30am and ends at 3:30pm. Drop off and pick up can be no earlier than 9:15am and later than 3:45. If campers arrive earlier or later then the designate time a cost of $1.00/minute will be charged.
Mobility Plus: If your son or daughter will be using Mobility Plus please ensure you provide summer camp staff with pick up and drop off schedule for the week and book timing as close as you can so that arrival is closest to the start time (9:30am).
Personal Items: Each Participant is asked to bring the following items daily: backpacks, sunscreen, bathing suit, hat and a change of clothes. We do ask participants to refrain from bringing personal items such as CDs, Mp3 players, Toys, etc…to the program in attempt to minimize loss or damage. Community Living York South and CLYS staffs are not responsible for lost or broken items.
Weather: Camp will not be closed due to weather conditions, however activities are adjusted accordingly. It is the individuals’ decision on whether they will attend.
Food: To ensure the safety of all food products that contain peanuts are not allowed at camp and we do not encourage the sharing of food. Also, because we will be doing outdoor activities, please send plenty of water for your son/daughter.
Medication: Camp staff are not trained nor permitted to administer medication.
Communication: Communication is extremely important to us at the camp and we encourage daily communication between the summer camp staff and home through the use of communication books. We encourage parents to keep the staff updated on all necessary information in the communication books.
Absence: For any reason if campers are to be absent, please notify the staff. We would encourage individuals who are ill to stay home. There will be no refund for any days missed.
Photo Consent: Taking pictures and capturing memorable moments at camp and contributing to our camp scrapbook project is a camp tradition. Please sign and return the photo consent form as soon as possible.
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I acknowledge I have read and agree with all the provisions contained in the terms and conditions.
Signature of Person Supported (16 years of age or over) Date
Signature of Parent/Guardian Date
:
I (Name of person Supported) ______________________________ hereby consent to use various mode of transportation for camp activities. It can include but is not limited to the use of public transportation, taxi, school bus, staff vehicles.
Signature of Person Supported (16 years of age or over)
Signature of Parent/Guardian
Date
Date
I____________________ hereby grant Community Living York South the absolute and irrevocable right and unrestricted permission in respect of photographic portraits or pictures, video or audio recordings, that have been taken of me or in which I may be included with others. Community
Living York South may use, publish, and republish the same photographs or recordings in whole or in part, individually, in any and all media now or hereafter, and for any purpose whatsoever, for illustration, promotion, art, editorial, and advertising.
I hereby release and discharge Community Living York South from any and all claims and demands arising out of or in connection with the use of photographs, including limitations any and all claims for libel or invasion of privacy.
I am of full age and have the right to contract in my own name. I have read the foregoing and fully understand the contents thereof. This release shall be binding upon my heirs, legal representatives, and assigns.
 By checking this box I give Community Living York South the right to use my name in association with my media likeness, if the agency so chooses.
If under 16: Check and initialed by parent.
Signature of Person Supported (16 years of age or over)
Signature of Parent/Guardian
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Date
Date