Camp Zenith is all the fun of the camp experience but enhanced by the specially designed programs intended to provide lasting therapeutic value.
Professional staff from the Rehabilitation Department at Children’s Hospital Colorado (who may include occupational, physical and speech therapists) work together with the wilderness educators from the Breckenridge
Outdoor Education Center (BOEC). Together, they plan the week’s activities with the needs of each participant in mind. Daily programs can include hiking, fishing, journal keeping, rock climbing, canoeing, overnight camping and a ropes course.
Values of acceptance, honesty, self-esteem and teamwork are encouraged throughout all camp experiences. Campers are guided in setting their own goals and achieving them to the best of their abilities.
The Camp Zenith summer program is intended for children 8 to 18 years of age who have sustained traumatic injuries to the brain.
A maximum of seven campers will be selected in order to ensure enjoyment, success and safety for each child. As much as possible, campers are grouped with abilities and camp experience in mind.
Since one to one supervision is not possible, all campers must be able to safely participate in an outdoor environment.
Campers should be able to tolerate the social stimulation that comes with active involvement in group living and activities during their stay at camp. Behavior that repeatedly disrupts the group process or puts the camper or others in the group at risk cannot be tolerated.
In addition, campers must be ambulatory for moderate distances on variable terrain and able to manage bladder and bowels with minimum assistance.
Again this year, camp will be held in the Griffith Lodge, which has indoor plumbing and is fully accessible.
th
Please note that families are responsible for transportation to and from camp.
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

Camp Zenith takes place at: Breckenridge Outdoor Education Center (BOEC) in Breckenridge, Colorado.
(1 hour 45 minutes west of Denver)
Scholarship assistance may be available, so please don’t let camp costs deter your child from participating. Payment for camp must be made no later than July 8 th .
Starting Cost of Camp
-
Charitable donations received by each camper
______
(**see statement below for additional funding available)
**Additional funding may be available via qualification and completion of the Financial Assistance Application included in this camp application. The Camp Zenith program is financed solely by philanthropic donations. Every attempt is made to make financial assistance available for individuals with identified needs. Resources for camper scholarships are subject to the amount of funds raised each year for this purpose. Camp fees are not billed to insurance providers.
th
To apply for camp Zenith, please complete the enclosed forms (list below) and return them to:
The Children’s Hospital – Parker Therapy Care
Attn: Emily Williams
19284 Cottonwood Dr. Suite 101
Parker, CO 80138
Or fax to 720-777-9063 (attn: Emily)
All applicants will be screened for appropriateness and must meet all of the requirements for involvement. Priority will be given to applications that are 100% completed and on a first come basis.

The Camp application

The Physician Permission form must be completed by your child’s primary care physician
 Children’s Hospital ColoradoLiability Release

BOEC Acknowledgement of Risk and Release of Liability
 Children’s Hospital ColoradoMedia Release

Authorization to Use and Disclose Protected Health Information

The Financial Assistance Application will be used to determine requests for need-based financial assistance for camp Zenith
For more information and a camp application, please call: (720) 777-3456. Our fax number is (720) 777-9063.
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

Please fill out this application completely.
Demographic Information:
Name (please print)_______________________________________________________________________________
Address/Street___________________________________________________________________________________
City_________________________________ State__________ Zip_____________Phone______________________
Age ______ Birthdate _____________ Sex ______ Height _______ Weight _______
Parent/guardian____________________________________E-mail____________________________________
Home phone_____________________________ Work phone ___________________________________
Name of person(s) to be notified in an emergency:
Name ____________________________________________________ Relationship________________________
Phone (h) ___________________________________ (w) _____________________________________________
Name ____________________________________________________ Relationship________________________
Phone (h) ___________________________________ (w) _____________________________________________
List any people you give permission to pick your child up from camp:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Describe how your child’s brain injury occurred:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Date of Injury:______________ Length of Hospital Stay:_______________ Discharge Date: ________________
Location of Hospitalization: ______________________________________________________________________
Medical History:
1.
Is your child covered by a hospitalization and medical care policy? □ Yes □ No
2.
If yes, name the insurance company : ___________________________________Policy # ___________________
3. Name of child’s doctor ______________________________________ Phone # ___________________________
4.
Within the last year, has your child had any illnesses, injuries of surgeries ________________________________
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

5.
List any medical diagnoses _____________________________________________________________________
6.
Does your child have any allergies? ______________________________________________________________
7.
List any dietary restrictions or precautions: ________________________________________________________
8.
Date of last physical examination: _______________________________________________________________
9.
Date of last tetanus immunization: _______________________________________________________________
10.
If your child has had any of the following conditions, please circle and give details at the end of the section:
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Any problem with vision or hearing - - requires glasses, hearing aid, etc.
Problems with teeth – use of braces, etc.
Dizzy spells, fainting, convulsions, persistent headaches, anxiety or vertigo
Frequent infections of throat, tonsils, sinuses, ears.
Chronic cough, bronchitis, bloody sputum.
Asthma or respiratory problems.
Palpitation of the heart, irregular heartbeat, heart murmurs, etc.
Poor circulation.
Jaundice or hepatitis.
Frequent abdominal cramping or severe menstrual cramps.
Difficulty urinating, pain on urination, bed wetting.
Frequent diarrhea or blood in stools.
Kidney infection or stones.
Spasticity, rigidity, poor muscle tone or limited range of motion
Catheter/leg bag
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Broken bones, joint dislocations, serious sprains.
Any severe injury to chest or internal organs.
Chronic skin problems, rashes, infections, etc.
Reaction to extremes of temperature, previous frostbite, poor circulation, etc.
Allergy to medicines, foods, insect bites, bees, etc.
Diabetes, thyroid trouble, bleeding problems.
Incontinence.
Sleep walking.
ADD (Attention Deficit Disorder), ADHD
(Attention Deficit Hyperactivity Disorder).
Other significant medical or neurologic disorders.
Any medications for diabetes, seizures or blood thinning.
Memory Loss
Non-Verbal
Sensory Integration Disorder
 Seizures/Epilepsy:
Date of last seizure __________________________Type of seizure _________________________________
Current status (active or controlled) ___________________Duration __________How often _____________
Describe reaction before, during and after seizure________________________________________________
______________________________________________________________________________________
Details of other conditions_________________________________________________________________________
______________________________________________________________________________________________
Medications:
Name of Medication Dosage Times Given Total Doses per day Reason for medication
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

How does he/she take the medication (chew, swallow with liquid, swallow with food, etc.)?
__________________________________________________________________________________________
__________________________________________________________________________________________
Do we have permission to give your child Aspirin or Tylenol in the case of a headache or minor pain?
□ Yes □ No □ Call first
I, ________________________________, acknowledge that I am skiing with a pre-existing condition of
_____________________________________________. I realize that there are inherent risks involved in adaptive skiing and will nto hold the BOEC responsible for nay injury.
______________________________________________________ _________________________
Patient Signature Date
______________________________________________________ _________________________
Parent/Guardian Signature Date
Self help skills:
1. Can your child dress himself/herself completely without help? □ Yes □ No (If no, what does your child need help with?___________________________________________________________________________________
2. Does your child need any help with hygiene? □ Yes □ No (If yes, what?)______________________________
3. Is your child fully potty trained? □ Yes □ No Does your child have any bowel or bladder trouble? □ Yes □ No
Therapy:
1.
Is your child currently receiving therapy? □ Yes □ No If yes, what is the frequency of the treatment?
Occupational Therapy _______ per month Therapist
Physical Therapy _ per month Therapist
Speech Therapy _ per month Therapist
Other _ per month Therapist
Phone # ___________________
Phone # ___________________
Phone # ___________________
Phone # ___________________
2.
Has your child had any of the above therapies in the past? □ Yes □ No If so, please describe: (please include any current or previous therapy reports that will help us know more about your child)
______________
Please look over all the categories below, and fill out any information in #1 - 6 that applies to your child:
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

PHYSICAL OR SENSORY DISABILITY
1.
Impairment in Mobility:
A.
Specific description of disability (include balance, coordination, endurance, etc.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
B.
Amount of strength and control in upper body and hands:
___________________________________________________________________________________
___________________________________________________________________________________
C.
Aids used:
_____ Cane
_____ Walker
_____ Short leg braces
_____ Long leg braces
_____ Helmet
_____ Back brace
_____ Special sleeping pads/supports
_____ Crutches
_____ Manual wheelchair
_____ Hand splints
_____ Communication Device
_____ Other:
_____ Special gripping devices
_____ Other:
Distance your child can walk ________________________________
D.
Needs assistance with (to what extent):
Walking (specify problems with any variation in surfaces)
____________________________________________________________________________
Transferring __________________________________________________________________
Eating _______________________________________________________________________
Toileting (are diapers worn?)_____________________________________________________
General hygiene ______________________________________________________________
Dressing _______________________________________________________________
Wheelchair pushing ______________________________________________________
Other _________________________________________________________________
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

2. Impairment in Vision
A.
Specific description of impairment (cause & degree)
____________________________________________________________________________
B.
Aids used
_____ Cane _____ Dog
_____ Glasses _____ Other:
_________________________
C.
What assistance is required _________________________________________________________
D.
General level of independence ______________________________________________________
___________________________________________________________________________________
3.
Impairment in Hearing
A.
Specific description of impairment (cause and degree)
___________________________________________________________________________________
B.
Communication skills and needs
_____ Interpreter required _____ Loud speaking required
_____ Slow speaking required _____ Other ______________________
C.
Comments ______________________________________________________________________
___________________________________________________________________________________
4.
Impairment in Cognition
A.
Describe the age level at which your child functions:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
B.
Does your child attend school?
_________________________________________________________________________________
Name of school/grade ________________________________________________________
Is your child in a special education program and/or require special assistance to function in the classroom (i.e., one on one supervision or frequent adult intervention?)
___________________________________________________________________________
___________________________________________________________________________
C.
Comments _____________________________________________________________________
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

5.
Difficulty with Communication
A.
Does your child understand what is said to him/her? _____ Yes _____ No
If not, please describe_________________________________________________________
B.
Does your child express his/her needs? _____ Yes _____ No
Please indicate how your child makes his/her wants known (i.e., sounds, one word phrases, gestures, etc.)________________________________________________________________
C.
Are there ways to assist your child in making his/her communication more successful?
_______________________________________________________________________________
D. What additional information does the camp staff need to know about your child’s communication skills?_____________________________________________________________
_______________________________________________________________________________
6.
Behavior Problems
A.
Has your child ever had a behavior problem? _____ Yes _____ No
If yes, please describe _________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
If yes, please share the best techniques for handling the problem ______________________________
___________________________________________________________________________________
B. Circle those that may apply to your child’s behavior:
Physical Aggression ( bites, hits, kicks, pulls hair, property destruction, sexual advances, self stimulation )
Verbal Aggression ( cursing, threats, inappropriate screaming, non-compliance, suicidal ideation )
Self Abuse ( biting, hair pulling, slapping, head banging, scratching )
Sleep Walks (how often) ___________________________________
C.
As one on one supervision cannot be consistently provided during camp, are there any specific fears or distressing situations which would cause your child to need additional behavioral redirection?
____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

OUTDOOR EXPERIENCE
1.
Please circle the appropriate response
Rock Climbing
Overnight Camping
Canoeing
Backpacking
Swimming
Ropes Course
None
None
None
None
None
None
Some
Some
Some
Some
Some
Some
Extensive
Extensive
Extensive
Extensive
Extensive
Extensive
Other:
2.
Please list any areas of restriction in the activities listed in #1 on the previous page that camp staff should be aware of.
______________________________________________________________________________________________
______________________________________________________________________________________________
3.
Please list other related skills or interests:
______________________________________________________________________________________________
______________________________________________________________________________________________
4.
Has your child attended any overnight camp before? _____ Yes _____ No
5.
Has your child attended a BOEC course before? _____ Yes _____ No
6.
Why are you interested in having your child participate in this camp? What would you like him/her to gain from camp?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
7.
Please share any other information about your concerns or your child’s needs that would help our staff plan a more enriching experience for your child.
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

I hereby affirm that I am the parent of legal guardian of __________________________________________
(participant) who has my permission to participate in a program of skiing provided by Children’s Hospital
ColoradoAssociation (Hospital) and the Breckenridge Outdoor Education Center (BOEC.)
I recognize that the Child’s participation in the skiing program and related activities involves risk of bodily injury and property damage and agree that the risk of any injury, loss or damage is assumed by the
Participant and the Participant’s parents or legal guardians.
I authorize BOEC and the Hospital to provide emergency medical treatment in the event the participant so requires and release the Hospital, BOEC and their respective officers, agents, employees and representatives from liability for all their decisions and actions, made and done in the good faith, in administering such emergency medical treatment.
In the event I cannot be reached in an emergency, I hereby give permission to a physician selected by the
Hospital and/or BOEC to hospitalize, secure proper treatment for and to order injection, anesthesia, or surgery for the above named Participant.
I release the owners and operators of BOEC, the Hospital, and their respective officers, agents, employees and representatives from legal responsibility for personal injury to the Participant, or loss or damage to the
Participant’s property resulting from participation I the skiing program and activities coincidental to it such as use of specialized sporting equipment, travel to and from the ski area, meals, rest and waiting periods.
Date Signature of Parent or Guardian
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

We, the staff of Breckenridge Outdoor Education Center (BOEC), look forward to having you, your child or your family member join us for a program experience on the ski slopes, at our Breckenridge campus and/or in one of our “wilderness” venues. On these two pages, you will find important information about BOEC, our activities and the potential risks involved in participation.
Please read this information carefully, ask us any questions you might have and do not sign this agreement if you do not want to be exposed to these activities and potential risks!
BOEC is a non-profit organization that has been in operation since 1976, providing outdoor adventure programs for people of all ages and abilities.** We offer activities and programs for groups and individuals throughout the year. BOEC strives to structure its activities to address the specific goals and abilities of its students.
All activities conducted by BOEC are consistent with the standards set out by the Association for Experiential Education (AEE) and the Professional Ski Instructors Association (PSIA). You can be confident in knowing that BOEC is accredited by AEE, an outside, independent organization that has reviewed and approved BOEC’s policies, practices and educational components. The
AEE only accredits those programs that meet its standards.
Please know that participation in BOEC activities involves risk. These risks will be greater than most people encounter in their daily lives, which is what BOEC is all about. Providing high quality programs in a risk-managed environment is a priority at
BOEC, however, we cannot eliminate all risks in adventure activities such as snow skiing or boarding, rafting, rock climbing or most of the activities that we do. These activities can cause injury and even serious injury. As with any outdoor adventure, under rare circumstances, the activity can even result in death.
It is of utmost importance to us that you not engage in activities that are opposed by you, your family, or your doctor due to illness, physical or mental infirmity, or any other health/medical condition that you may have, whether diagnosed or undiagnosed.
To help us try to manage these risks it is very important that all program participants follow all directions given by BOEC staff.
Please ask questions whenever a procedure or activity is unclear to you. If a program participant currently is taking prescription medications, including medical marijuana or other alternative therapies, it is imperative that these medications be disclosed in the confidential medical form. Use of or being under the influence of alcohol or judgment affecting drugs while participating in adventure activities is unsafe and strictly prohibited.
We believe that it is in everyone’s interest that risks are disclosed, understood, and accepted prior to participation at BOEC. After you have reviewed both sides of this Acknowledgement of Risk and Release of Liability Form and if you understand and agree with its contents, please sign and initial in the designated places on both pages. If you are the parent or legal guardian of a student, again please read both sides of this form and if you both agree and understand their content, place YOUR signature and initials in the designated places on both pages.
If you have any questions or comments about this Release or the level of risk at BOEC, please do not hesitate to contact us. We welcome your questions, suggestions and feedback.
Sincerely,
The BOEC Staff I have read the above information
Participant or Parent/Guardian __________(initial)
** BOEC is not owned or controlled by Breckenridge Ski Resort, Keystone Ski Resort or the Town of Breckenridge.
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

I.
Permission to obtain medical treatment on my behalf ______Agree (initial)
I, or the person for whom I am the legal guardian, hereby give permission for BOEC Program Staff to render first-aid and to seek emergency medical or rescue services as they see fit, and at my cost. (Please note: We recommend that all BOEC participants be covered by personal health insurance. If medical care for injury, pre-existing condition or any other reason is required during a
BOEC course, the participant’s personal health insurance will be primary).
II. Permission to take and display images
(initial)
______Agree
I, or the person for whom I am the legal guardian, hereby give permission to BOEC, and any person designated by BOEC, to make photographs and other recordings of myself, and I consent to publishing and/or displaying of such recordings as BOEC deems fit for the sole purpose of promotion of BOEC.
My signature below represents that I, as a participant or as the parent of a minor participant or as the legal guardian of a participant, (hereinafter, collectively, “I”) have read and understand the contents of this release. In consideration for being allowed to participate in Breckenridge Outdoor Education Center (BOEC) programs, and related events and activities, or serve as staff or volunteer for the same, I hereby understand and agree to the following:
1.
I understand that although BOEC has taken precautions to provide proper organization, supervision, instruction and equipment for each activity, it is impossible for BOEC to guarantee absolute safety.
2.
I understand that I share the responsibility for safety during all activities, and I accept that responsibility. I will make my instructors aware of any questions or concerns I might have regarding safety standards, guidelines, procedures and my ability to participate in an activity.
3.
I understand that participation in outdoor programs involves risk. The following is a partial list of the potential risks associated with the activities at BOEC. This list does not include all inherent risks but serves to provide examples and promote an understanding of the risks, any of which could result in injury, mental stress, permanent disability, or even death.

Complications associated with exposure to weather (including extreme cold, wet or icy conditions, heat, sun, lightning), altitude and physical exertion

Perils and hazards arising from unintended contact with others, including participants and members of the general public

Perils and hazards arising from unintended contact with both natural features such as rocks, trees, plants and
4.
animals, as well as man-made features such as posts and equipment

Perils and hazards arising from equipment failure or malfunction

Increased risk of harm due to delays in the delivery of emergency medical services in remote locations or due to reasons beyond BOEC’s control
I understand that in addition to the risks inherent in all activities at BOEC, more specific risks accompany each type of activity. For example, skiing, snowboarding and other snow-based activities expose participants to slips, falls and collisions with trees, obstacles and other parties. Rafting, canoeing, kayaking and other water based activities expose participants to drowning or other complications associated with immersion in water and cold water, falling into water and/or swimming in turbulent water, becoming pinned or entrapped by items or obstacles in/on the water, colliding with rocks, boats and other items in the water, and falling while entering or exiting any boats. Biking, climbing, ropes course and other land based activities expose participants to falls from heights and obstacles, high speeds and sudden stops, trauma resulting from being fully supported in a harness for an extended period, collisions, and opportunities to become lost.
5.
I understand that I have the right to inspect the facilities and equipment to be used, and to observe a lesson or program, and that if I believe anything is unsafe, it is my responsibility to immediately advise BOEC staff of such condition and refuse to participate.
6.
I assume all the foregoing risks, as well as similar unforeseen risks, and accept personal responsibility for the damages due to such injury, permanent disability or death resulting from participating in any BOEC activity.
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

7.
Should I have a disagreement or dispute with BOEC about this Release, the charges, the activities, any injury I may receive or any other aspect of BOEC, I agree that any action to resolve or redress such disagreement or dispute will be brought in
Summit County, Colorado and governed by Colorado law.
I hereby release BOEC, its successors, representatives, assigns, Board of Directors, volunteers, employees, officers and other participants from any and all claims, demands, and causes of action, whether resulting from negligence or otherwise, of every nature and in conjunction with a BOEC activity.
I have read this Agreement, understand its contents, am aware this document has legal consequences and I sign it voluntarily.
____________________________________ ________________________________ ________________
PARTICIPANT’S PRINTED NAME SIGNATURE DATE
Parent or Legal Guardian (if participant is under 18 years of age or otherwise legally dependent):
I hereby warrant that I have legal authority to act on behalf of my child or ward. I agree to the above terms and conditions for myself and on behalf of my child or ward. I agree to indemnify BOEC for any and all claims brought by or on behalf of the child or ward for whom I sign or for any claim brought by any other person related to the child or ward against BOEC.
_____________________________________ ________________________________ _________________
PARENT/GUARDIAN’S PRINTED NAME SIGNATURE DATE
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

680330 (Rev 9/07)
Health Information Mgmt / TCH / 13123 E. 16 th
Avenue Box 150 / Aurora, CO 80045 720-777-
Patient Name __________________________________________________________ MR#_________________
Last First MI (completed by TCH)
Birth date _________________________ Phone____________________ SS# _________________________
Parent/Guardian/Requester Completing Form: ___________________________________________________
I authorize Children’s Hospital Coloradoto Release Medical Record
Information to:
Name __Breckenridge Outdoor Education Center__
Address ______________________________________________
City/State/Zip ____Breckenridge, CO____________________
Phone __________________________ Fax ___________________
For the following purpose:
□
Continuation of Care
□
Insurance
□
Legal
□
Personal Use
□
Other __________________________
Treatment Dates: From__________________________________
To__________________________________
□
Pertinent Information ( Discharge Summary, H&P, X-Ray, Lab, Surgery, EKG, etc )
□
Emergency Room/Urgent Care
□
Immunization Record

Clinic Information/Notes
□
Lab Reports
□
Discharge Summary
□
Imaging Results
□
Copy of Images
□
Complete Medical Record (except ________________________)
□
Other________________________________________________
State/Federal Laws require specific authorization to release the following types of information. Please initial beside the types of information to be released:
____ HIV/AIDS Related ____ Genetic Testing ___ Drug/Alcohol abuse
____ Mental Health ____ Psychotherapy Notes ___ Sickle Cell Anemia
□
Call Requester for pick-up when records are ready.
□
Mail records directly to person or organization specified.
□
Other _______________________________________________
I authorize ___________________to pick up my Medical Records.
_______________________________________________
Relationship to patient
The following fees are applicable and authorized by Colorado State Law:
$ 14.00 - 1 - 10 pages
$ .50/pg - 11- 40 pages
$ .33/pg - each add’l page
$1.50 per page for microfilm
X-Ray film - $14.00 per sheet
X-Ray CD - $14.00 per CD
Confirmation of Pick Up:
_________________________
Signature
Date ___________
___CD __ Film ___ Checked out Existing
Film
I understand that : (1) My signature on this form is strictly voluntary. (2) I may revoke this authorization at any time in writing, and if I do it will not have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy
Practices. (3) If the requester or receiver is not a health plan or health care provider, the released information may be disclosed by the recipient and may no longer be protected by federal privacy regulations. (4) If I do not sign this form, my health care, the payment for my health care or my ability to enroll for benefits will not be affected. (5) I may inspect or obtain a copy of the health information that I am being asked to disclose.
Expiration: Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event will expire 180 days from the date hereof, unless otherwise specified: ______________.
□
If this “box "is checked, the Facility will receive compensation for the use or disclosure of my information.
____________________________________ ___________________________ __________
Signature Relationship to patient Date
4259 / Fax 720-777-7251
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

Child’s Name: ________________________________________ Birth date: _____________
Father’s Name: _______________________ Mother’s Name: ________________________
Marital Status: Married Single Divorced Separated (circle one)
Telephone: __________________________ How long at present address? ____________
Number of children in family: ________ Ages: _________________________
Financial Information
Father’s Employer: _____________________________________ How long? ______ Telephone:_______________
Father gets paid: Weekly Every 2 weeks Monthly (circle one)
Amount of take home pay each pay period _____________________
Mother’s Employer: _____________________________________ How long? ______ Telephone: ______________
Mother gets paid: Weekly Every 2 weeks Monthly (circle one)
Amount of take home pay each pay period ____________________
Other sources of income and approximate dollar amount received from each source:
_____________________________________________________________________
Checking Account Balance (approximate): ______________________________________
Savings Account Balance (approximate): _______________________________________
Automobiles: Model/Year ____________________ Model/Year __________________
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

Expenses
1. House Payment or Rent
Original Balance Current Balance Monthly Payment
2. Utilities (gas, elec., water, phone)
3. Groceries
4.
5.
6.
Has your child received Camp Financial Assistance previously? ___________________________
List any other resources you have, or are in the process of contacting, for financial assistance for camp (such as local service organizations, like Kiwanis, or town or county community boards or groups):
______________________________________________________________________________________________
2.
Estimation of amount family can pay: $ ________________________
Your application cannot be reviewed without the following:
1. Current paycheck stub available).
or letter of explanation regarding source of income (if paycheck stub is not
Estimation of amount family can pay toward child’s participation.
I hereby certify the above to be true to the best of my knowledge.
SIGNATURE: _________________________________________________________________
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045

To be filled out by the child’s primary care physician
Date :
Name Birth date
Address
City Zip
Home Phone Work Phone
Parents/Guardians
Diagnosis/Reason for Referral
Comments (include precautions)
I give my permission for the above named patient to participate in camp with Children’s Hospital ColoradoCamp
Zenith program with Breckenridge Outdoor Education Center.
Physician’s Signature:
Print Physician’s Name:
Camp Zenith: For Children with Brain Injuries (720) 777-3456
Children’s Hospital Colorado| Anschutz Medical Campus | 13123 East 16 th Avenue, B285 | Aurora, CO 80045