-*
R4t,,r0
.- , S c.·\-
'"'of'(\
\l
GENERAL FORM
• EACH CAMPER, (lustrnctions la and 2-5):
• EACH VOLU NTEER (lnstrnctions lb and 2-5):
In. Stroke Survivors and Families, nlease complete the following, then go to 2:
D
I have not attended the Stroke Retrea t in the past. [Please complete and attach
"Camper Application" (Choose either full weekend or day ca mp, one per fa mily unit).]
0 The last time I attended was prior to 2007.
[Please complete and attach "Camper
Application" (Choose either full weekend or day camp, one per family unit).]
D I attended in 2007 or more recently, and have records on file* [Please complete and
a ttach "Camper Applica tion Short Form", (Choose eit her full weekend or day ca mp, one
per family unit).]
l b. Volun teers, please complete the following, then go to 2:
D I am a volunteer.
(Please complete and attach "Volunteer Application Form".
2. Please sign and return RELEASE AND INDEMNIFICATION form .
3. Please sign and return the form: "Cam per Authorization to Conta ct Heat h Provid er &
Health Care Provider Health Form for Partici pant s."
3a. If you h an a /1iston 1 o{ stroke or ot h er sig11iOcr111t !tea/tit issues, pl ease ask your hea l t h care
prov ider to complete part 3 of tlteform "Camper Authoriza tion to Con tact Heath Provider &
Health Ca re Provider Health Form for Participants" .
3b. If you do not have a history of stroke or other significa nt health issues, you do not need to
complete part 3. Instead, please check here: 0 I do not have significan t health issues.
4. Please complete "Camper Health History and Authorization" or the "Camper Health
History Short Form", (if you a re a returning camper with records on file*).
5. Please sign and return this form.
Part icipant Na me (please pri nt): ----------------Partici pant Signat ure: ------------------
date : ----
*Record s on file since 2007.
Genera l For m
Page I of I
Revi ew elate: I /5/20 16
STROKE RETREAT 2016 - CAMPER APPLICATI ON (Short Form, full weekend)
I attended Stroke Retreat Camp in 2007, or more recently, and have records on file.
(Please complete the remainder of this form I)
(If the statement above is not true, please do not complete this form. Please complete
form "Stroke Retreat 2013 - Camper Applicati on".)
Please complete all the requested information in each section. Return with your registration
fee of $75.00/person ($35.00 for children age 5-14, children under 5 are free), payable to:
Stroke Retreat
Henry Ford Health System
Stroke Survivor
Name:
Address:
Cit :
State:
Phone:
E-mail:
Birth Date:
A e:
ZIP:
Sex:
Caregiver/Companion/Emergency Contact Please note that we encourage all stroke swvivors to bring a
caregiver or companion wit/1 them. Please list t11em below. If you do not /Jave a caregiver or companion who is
able to attend with you, please identify the name, address and telephone number of an emergency contact who,
in the case of an emergency, is able to pick you up from camp or the hospital, night or day. (Camp volunteers
are not allowed to transport campers for liability reasons.)
Caregiver/Companion/Emergency
Contact
Name:
Address:
Cit :
State:
Phone:
E-mail:
Birth Date:
A e:
ZIP:
Sex:
Is this person?
D
Caregiver attending camp
D Companion attending camp
D Emergency Contact for
transportation
I am attending with the same group of family members that attended last year:
D YES
Camper App-short 201 6
Page I of 2
Revision elate: 1/25/2016
O NO - if no, please list participants below:
Additional Family Members Attending Camp:_O NONE 0 see below
(Please note - all participants must have the correct forms completed to attend the Stroke Retreat.)
Name:
A e:
Sex:
Name:
A e:
Sex:
Name:
A e:
Sex:
Name:
A e:
Sex:
Please list additional persons on the back of this form.
Please describe any assistance required during camp:
Will you or your family require a special diet?
D
Yes
D
No
If yes, please describe the special diet and include the names of all family members who require the diet:
Cabin Assi gnments
You will be placed into a cabin with compatible families or same sex groups. Cabins are rustic and have beds
for 6-9 people, with one bathroom and one changing room. (You will need to bring your own bed linen and
towels.) Please mark cabin preference below. We will try to match cabin mates as appropriate and as space
allows.
0
D
Female cabin
D
Male cabin
D Couples cabin (adults only)
D Family cabin (children)
No cabin reservation needed. Will stay off-site. (Can1pers staying at local hotels are responsible for pay111ent and for 1naking
their own f1otel reseNations. A list of hotels will be sent to you.)
Please list other individuals you wish to room with:
Please list any other information you feel we should know about your family:
Cmnper 1\pp-short 201 6
Page 2 of 2
Revision date: 1/25/20 l 6
STROKE RETREAT 2016
RELEASE AND INDEMNIFICATION
Please have each participant read and sign a copy of this form.
The Stroke Retreat involves walking over bumpy terrain, exercise, swimming, etc.potentially hazardous activities that may include risks such as, but not limited to, falls, contact
with other participants, effects of weather and exposure to cold and heat. In consideration of
being allowed to participate in this event, I hereby expressly assume all risks, including
personal injury and death, arising out of my participation in the Stroke Retreat and related
activities.
It is my responsibility to provide and properly use protective clothing and equipment, and to
ensure that all clothing and equipment are properly fitted and appropriate for use in this
event. Although refreshments and other assistance may be made available during this event,
I am solely responsible for my own health and safety. I represent and warrant that I am
physically fit and able to participate in the Stroke Retreat. I agree to stop and request
assistance if I experience any symptoms such as, but not limited lo, dizziness, excessive
fatigue, and shortness of breath, pain or any other conditions which would make ii difficult or
unsafe to continue.
I agree, for myself, my heirs, executors and administrators, to 'not sue and to release,
indemnify and hold harmless, Henry Ford Health System or its affiliates, officers, directors,
volunteers and employees and all sponsoring businesses and organizations and their agents
and employees, from any and all liability, claims, demands, and causes of action whatsoever,
arising out of my parlicipation in this event and related activities - whether it results from the
negligence of any of the above or from any other cause.
The foregoing release and indemnification agreement shall be as broad and inclusive as is
permitted by the State or Province in which the event is conducted. If any portion of iiis held
invalid, the balance shall continue in full force and effect.
I have read, understand and agree to the terms of this Agreement.
inde111nification 2016
Page I of 2
Revision: 1/5/2016
STROKE RETREAT 2016
RELEASE AND INDEMNIFICATION
If Participant is a minor, parent or guardian must sign below:
I am the legal guardian of Participant, and I hereby consent to his/her participation. I have
read the foregoing release and indemnification agreement, and I hereby agree on behalf of
myself and Participant to its terms.
ParenUGuardian's Signature: ----------------------Printed Name of Guardian:
------------------------
Printed Name of Participant: -----------------------Date:
-------------------------------
indc1nnification 2016
Page 2 of 2
Revision: l/5/201 6
Camper Authorization to Contact Health Provider
& Health Ca re Provider Heal th lf orm for Pa rtici pa n ts
PART I
I authorize the Stroke Retreat Camp Director, Medical Director, or their
designated volunteers to contact my health care provider, and/or to review my
health records, to discuss my health status and determine ability to participate in
camp. I authorize my health care provider to release information related to my
current state of health and my ability to participate in camp.
Participant signature:
Date:
_
Printed name of Participant: ------------------
PART 2
In case of accident, illness or injury at camp, I authorize the Stroke Retreat Camp
Director, Medical Director, or their designated volunteers to contact my health
care provider, discuss my health status, and/or to review my health records.
Participant signature:
Date:
_
Printed name of Participant: ------------------
Health Care Provider Printed Name:
Office Address:
--------------------
Ad d
ress------C ity------'---Sta te
----Z
IP
7
Office Phone:
-
------------Office Fax: -----------
Camper Authorization to contact health provicer
Page I of 2
Revision date: 1/25/20 l 6
See our website at: www.hcnryford.com/st rokerct reat
Camper Authori zation to Contact Health Provider
& Health Ca re Provider Health Form for Pa rticipa n ts
PART 3
Camper Authorization & Health Care Provider Health Form
Printed Name of Participant: -------------------Dear Health Care Provider:
Your patient noted above has applied to participate in a stroke survivor camping weekend as a
stroke survivor, friend or family member, or volunteer. They have identified that they have
significant health issues. Camp offers many benefits, including a supportive environment that
provides socialization among stroke survivors and families; supervised, accessi ble activities;
input from trained health care professionals including speech therapists, physical and
occupational therapists and other health care providers experienced in stroke care; an
opportunity for fun and relaxation for all; and respite for family members.
Cabins and camp buildings are ramped for wheelchair accessi bility. However, the distance
between buildings can require walking or ability to maneuver wheelchai rs a great distance. This
can be stressful for some campers. There is the potential for falls from uneven ground in some
areas. Campers in wheelchairs can be accommodated at camp if they can transport themselves,
or with family assistance, or have motorized chairs. We have volunteers to assist campers when
requested.
Although there will be health care providers including physicians on site, medical treatment is
limited to basic first aid. Emergency services are available through 911 access of the local
emergency ambulance transport system.
Please indicate whether you feel your patient is able to participate in camp fully, with restrictions,
or not at all. If you have questions, please contact Sheila Daley, RN, at (313) 575-4373.
0 I feel my patient is fully able to participate in camp.
0 I feel my patient can participate in camp with the following restrictions:
D I recommend that my patient not participate in camp for the following reasons:
Health Care Provider Signature:
Health Care Provider Printed Name:
0ffice Address:
Address
Date:
_
----------------------
-----------------------------
Office Phone:
Please mail or FAX (313 916-8007) this
i nformat ion to: All n: K issie Harr is
Stroke Retreat
Henry Ford Health System
CFP-126, Surgery Admin
Detroit, Ml 48202
City
State
ZIP
Office Fax: ------------
Page 2 of 2
Revision dale: l /25/2016
See our website at: www.henryford.com/strokerct reat
CAMPER HEALTH HISTORY and AUTHORIZATION - Short
Form STROKE RETREAT 2015
All health-related or personal information being collected for the Stroke Retrea t is solely to be used in prepa ra tion for the even t
and in case of a 1nedical e1nergcncy. All infotn1a tion \Viii be kept secured prior to, during the event, and after the event. All
forms will be destroyed or retu rned at you r req uest.
Returning campers who have attended the Stroke Retreat in 2007 or more recently, please complete all
requested information in the sections below. All others use the "Camper Health History and Authorizati on"
form. No health history forms are on file prior to 2007.
Return to:
Kissie Harris
Surgery Admin-CFP126
2799 W. Grand Blvd.
Detroit, Ml 48202
CAMPER NAME:
ADDRESS:
CITY:
STATE:
ZIP:
_
TELEPHONE:
BEST TIME TO CALL: ------
BIRTHDATE:
--------------AGE: ------- SEX: 0Male 0Female
INSURANCE COMPANY:
_
INSURANCE NUMBER: (please bring cards to camp) ---------------PHYSICIAN NAME: ------------------------PHYSICIAN
PHONE:
--------------------------
PARENT OR GUARDIAN NAME (if applicable): ---------------ADDRESS AND PHONE (if different from above): -----------------
c<impcr_history_Sl-IORT_FOR d 20135
Page 1 o!'3
Revised: 2/5/2015
CAMPER HEALTH HISTORY and AUTHORIZATION - Short Form
STROKE RETREAT 2015
D I supplied a complete health history form for camp in (year)
, (If this statement is
not correct, please use the form "Camper Health History and Authorization" instead of this short form)
and since that time:
O I have not had any changes to my health (no new medical conditions, hospitalizations,
operations or procedures) since last attending camp .
O I have had the following changes to my health (list any new medical conditions, new
strokes, hospitalizations, operations or procedures) since last attending camp. (Please
List):
(if more space is needed to list medical conditions, surgery or procedures, please use the
back of this form.)
Has your level of activity decreased since you last attended camp?
O no
D yes (describe, and identify any new requirements for support or special needs).
List New Medications:
Is there anything else we should know about your health? D no D yes:
camper_history_ SI IORT_FOR vl 20 !JS
Page 2 of 3
Revised: 2/5/2015
CAMPER HEALTH HISTORY and AUTHORIZATI ON - Short
Form STROKE RETREAT 2015
AlJTl-IOR I ZATIONS
The health history contained in this application is correct so far as I/we know and the person herein has described
permission to engage in all prescribed camp activities, except those noted by us and/or examining physician. I
certify to the best of my knowledge I/my child does not have any contagious disease or condition. I also
understand that neither Henry Ford Health System nor the camp is responsible for illness due to previous poor
health conditions.
If there should be an emergency while at camp, I/we authorize treatment by the Henry Ford Health System camp
medical staff. The Henry Ford Health System/ camp medical staff is able to evaluate and treat most minor
illnesses and injuries as well as stabilize serious medical conditions. I/we also attthorize routine treatment by the
Henry Ford Health System/ camp medical staff during the weekend of camp. I/we authorize the Henry Ford
Health System stroke camp director or medical director to use their best knowledge to select and designate
nurses, physicians, and/or surgeons to finish nursing, medical, and/or surgical care should it be necessary and
the admittance to a hospital in case of an emergency. I/we further absolve the Henry Ford Health System/ from
any and all liability for their reasonable acts done in good faith.
In the event of a serious medical problem, the camp medical staff or the Henry Ford Health System camp director
or medical director will contact local emergency support services (911) and parents or persons listed below to
advise them of the camper's condition, treatment, or need for continued medical attention. Please list at least
one person not attending camp.
In case of en1ergency, please contact:
Alternate emergency contact:
Narne:
_
Nan1e:
Relationship:
_
Relationship:
City:
Day Phone:
_
_
City:
Day Phone:
Evening Phone: ---------------
Evening Phone:
Camper Signature
Parent Signature (if under age 18)
date
date
l'ampcr_history_ SJ IORT_FOR!'vf 20135
Page 3 of 3
Revised: 2151201 5