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Rocky Mountain Village Summer Camp Application 2015
P. O. Box 115 Empire, Colorado 80438
Phone: (303) 569-2333 or Fax: (303) 569-3857
Rocky Mountain Village is operated in accordance with the US Department of Agriculture policy, which prohibits discrimination on
the basis of race, color, sex, age, disability, religion, or national origin. Rocky Mountain Village is a program of the Easter Seals
Colorado. The following information is confidential. It is required to assist camp personnel in making the applicant’s camp experience
positive and more enjoyable.
Sessions fill quickly, based on a first come first served basis.
Summer Camp Session/s: Children’s
Hospital Colorado
TALKING WITH TECHNOLOGY CAMP July 19-24, 2015
Please fill out the following information COMPLETELY. For the safety of your camper, we require at
least three different people/places to contact in case of an emergency.
Emergency Contact Information:
Contact #1 Information Parent(s) ____ Legal Guardian ____ Caregiver/Host Home Provider ____ Other _____________
Name:______________________________________________ Email:__________________________________________________
Mailing Address:_____________________________________________________________________________________________
City: _________________________________________________ State: _______________________________ Zip: _____________
Check here if this is where correspondence should be mailed: ___
Physical Address of Camper (if different than above)_________________________________________________________________
City: _________________________________________________ State: _______________________________ Zip:______________
Home Phone #:_______________________ Evening Phone #:________________________ Cell Phone #:______________________
Place of Employment:__________________________________________________________________________________________
Contact #2 Information Parent(s) ____ Legal Guardian ____ Caregiver/Host Home Provider ____ Other _____________
Name:______________________________________________ Email:__________________________________________________
Address:____________________________________________________________________________________________________
City: _________________________________________________ State: _______________________________ Zip: _____________
Check here if this is where correspondence should be mailed: ___
Physical Address (if different than above)__________________________________________________________________________
City: _________________________________________________ State: _______________________________ Zip:______________
Home Phone #:_______________________ Evening Phone #:________________________ Cell Phone #:______________________
Place of Employment:__________________________________________________________________________________________
Contact #3 Information Parent(s) ____ Legal Guardian ____ Caregiver/Host Home Provider ____ Other _____________
Name:______________________________________________ Email:__________________________________________________
Address:____________________________________________________________________________________________________
City: _________________________________________________ State: _______________________________ Zip: _____________
Check here if this is where correspondence should be mailed: ___
Physical Address (if different than above)__________________________________________________________________________
Contact Information:
Camper’s Last Name _______________________First Name __________________Middle Name ____________Gender_____
Mailing address for camper:
_____________________________________________________________________________________
City___________________________________________________________State _____________Zip_________________________
Check here if this is where correspondence should be mailed: ___
Physical Address of Camper (if different than above)_________________________________________________________________
City____________________________________________________________ State_____________ Zip_______________________
Home Phone #:_______________________ Evening Phone #:________________________ Cell Phone #:______________________
E-Mail address:______________________________________________________________________________________________
Date of Birth:_____________________________________________________________ Age:______________________________
Phone Number: Home (______)__________________________________ Work (______)__________________________________
Ethnicity (this information used for statistical purposes only):
____ Asian American
____African American
____Caucasian
____Hispanic
____Native American
___Other ___
Education:
____Less than 12 yrs ___High School grad or GED
Camper Name: __________________________________________________________________________________________________________ Page 2
Agreement, Consent and Release:
With the understanding that Easter Seals Colorado will make every reasonable effort to prevent accidents, injuries or other mishaps, I
acknowledge the following:

The undersigned agrees to indemnify and hold harmless Easter Seals Colorado – Rocky Mountain Village for any and all
claims, demands, costs, expenses, including reasonable attorney’s fees that Easter Seals Colorado may suffer as a result of
any claim, action, demand or judgment against it arising from the attendance at camp by this applicant. Provided, however,
that the above and foregoing shall not be construed to indemnify the Easter Seals Colorado from any act of negligence or
fault on the part of Easter Seals Colorado, its officers, agents or employees.

The undersigned does consent that photographs, video or motion pictures may be taken of the named applicant during the
camp period, and that said photographs, video or motion pictures may be published in newspapers, magazines, television,
web site, publicity releases and/or other media.

The undersigned, in case of emergency and in the event the undersigned cannot be reached by telephone, does hereby give
permission for medical treatment by a physician or hospital selected by the Camp Director. Such permission shall include any
and all medical treatment which is necessary or desirable in the absolute discretion of any such physician or hospital. This
medical care shall include, but is not limited to, examinations, treatments, immunizations, injections, anesthesia, surgery, and
other procedures, etc.

The undersigned does hereby agree to allow participation of applicant in all camp activities (except those restricted).

The undersigned gives permission for the applicant to ride in vehicles operated or leased by the Easter Seals Colorado –
Rocky Mountain Village.
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The undersigned recognizes the right of the Camp Director, in his/her absolute discretion, to terminate a camper’s stay at any
time due to disciplinary or medical actions which might jeopardize the camper’s or others’ health and safety at camp. The
undersigned further agrees to pick up the camper immediately upon being notified of such termination. Full camp fees are
nonrefundable in case of above mentioned situations.

The undersigned agrees to pay the full camp fee if the camper cancels one week or less prior to the check in day. This
includes not arriving on check in day.

The undersigned agrees not to send the applicant to Rocky Mountain Village if he or she has been exposed to a contagious
disease within three (3) weeks of the starting date of camp, and to notify Rocky Mountain Village if this situation arises.

Weapons, pets, drugs and alcohol are not allowed at Rocky Mountain Village. An exception may be made for trained guide
dogs for campers who require their services. The dog’s owner assumes all responsibility for the care and actions of the dog.
The dog must be free of disease and have a current rabies license or tag. Dogs that exhibit any behaviors that put Easter
Seals’ staff, campers or visitors at risk will not be permitted to remain. Costs to have the animal removed from the camp will
be at the owner’s expense. A copy of the dog’s vaccines is required.

If someone other than the undersigned is to pick up the applicant at the end of the camp session, such person must present
written authorization from the undersigned. I do hereby authorize to pick up camper.________________________________
_______________________________________________________________________________________
(Name)
(Address)
(City)
(State)
(Zip)

Please list anyone in particular you do NOT want to pick up your child or adult.____________________________________

In witness whereof I have hereunto executed this Agreement, Consent & Release on this date:
LEGAL GUARDIAN’S SIGNATURE:____________________________________ Date: ______________
LEGAL GUARDIAN’S PRINTED NAME:____________________________________________________
Camper Name: __________________________________________________________________________________________________________ Page 3
Camper Information:
This information is mandatory and will be used to determine whether the applicant’s needs can be
met adequately at Rocky Mountain Village. All important information relative to the camper’s health and well-being should be on
the application. DO NOT rely on verbal instructions at the time of registration to communicate important information about your
camper.
PRIMARY DISABILITY:____________________________________________________________________________________
SECONDARY DISABILITY:
___Cerebral Palsy
___Spinal Cord Injury
___Spina Bifida
___Autism
___Developmental Disability
___Down Syndrome
___Traumatic Brain Injury
___Seizure Disorder
___Muscular Dystrophy
___Hearing Impaired
___ Visually Impaired
___Diabetes
___ADD/ADHD
___Hemaplegia
___Multiple Sclerosis
___Learning Disability
___Dyslexia
___Terminally Ill
___Psychosis
___Normal Functioning
___Other: __________________________________
RATIO:
Please check the ratio of care (camper:counselor) required in each area for the applicant:
Physically:
___1:1
___2:1
___3:1
___4:1
Socially:
___1:1
___2:1
___3:1
___4:1
MEALTIMES:
Eating:
Diet:
___No Assist
___Partial Assist
___Total assist
___ Normal
___ Chopped
___Blended/Pureed
___ Low Cholesterol
___Low Salt
___Low Fat
___Celiac
___Gluten Free
___Low Calorie/# of calories__________________
___Diabetic/# of daily calories ________________
___G-tube (please attach feeding schedule)
___other__________________________________
___Typical
___Small
Typical Appetite: ___Large
Food Allergies/Problem Foods: ___________________________________________________________________________
____________________________________________________________________________________________________
Does applicant have difficulties swallowing? ___Yes
COMMUNICATION:
Hearing:
___No
___Normal
___Hard of Hearing
___Total Loss
___Wears Hearing Aids
Vision:
___Normal
___ Legally Blind
___Total Loss
___Glasses/Contacts (please label glasses)
Speech :
___Normal
___ 2-3 word phrases
___1 word phrases
___Vocalizations/Sounds
___Pictures/word cards
___Other __________________
___Sign Language
___Gestures
___Adaptive communication device; describe________________________________________________
Comprehension: ___Understands complete sentences
___Understands sign language
___Understands single words
___Able to read
How does camper express his/her own needs? ______________________________________________________________
___________________________________________________________________________________________________
Camper Name: __________________________________________________________________________________________________________ Page 4
MOBILITY:
___Ambulatory ___Wheelchair (Manual) ___Wheelchair (Electric) ___Walker
___Scooter
___Crutches
___Cane
Does camper independently operate wheelchair?
TRANSFERS:
___No Assist
___Stand-By Transfer
___Other:____________
___Yes
___No
___Total Assist Transfer ___Hoyer
___Other, describe:____________________________________________________________________
ADAPTIVE
DEVICES:
___None
___AFO’s/Braces
___Prosthesis
___Helmet
___Dentures
__Other, describe:______________________________________________________________________
TOILETING:
Bladder Control:
___Normal
___Needs Reminders
___Incontinent
Bowel Control:
___Normal
___Needs Reminders
___Incontinent
Aids Used:
___None
___Urinal
___Catheter (Indwelling Condom, Self)
___Toilet Chair ___Diapers/Briefs
___Ostomy
___Suppositories ___Enema
___Other:__________________________________
Describe Toileting Schedule:____________________________________________________________________________________
____________________________________________________________________________________________________________
Specific Bowel Program; describe: _______________________________________________________________________________
____________________________________________________________________________________________________________
Describe related behavior or disruptive toilet habits:__________________________________________________________________
____________________________________________________________________________________________________________
Does applicant menstruate?
___Yes
Is she independent with her menstrual care?
___No
___N/A
___Yes
___No
If no, what assistance does she need? _____________________________________________________________________________
Does she experience cramps?
___Yes
__No
Special instructions: ___________________________________________________________________________________________
WASHING/BATHING:
Camper needs assistance with the following:
__shampooing
__brushing teeth
__needs complete assistance in shower
DRESSING
__No Assist
__Partial Assist
__soaping
__needs verbal cues
__adjusting water temp
___showers independently
__Total Assist
If you marked “partial or total assist” please explain:_________________________________________________________
__________________________________________________________________________________________________
Camper Name: __________________________________________________________________________________________________________ Page 5
SLEEPING:
Does applicant have trouble sleeping?
___Yes
___ No Please explain:______________________________________
__________________________________________________________________________________________
Need to be awakened/turned at night?
___Yes
___ No Please explain:______________________________________
__________________________________________________________________________________________
Can applicant sleep on upper bunk?
___Yes
___No
Does applicant need bed rails?
___Yes
___No
Does applicant have a night attendant at home?
___Yes
___No
 If yes, applicant is responsible for bringing night attendant with him/her to camp. Prior arrangements must be made
through camp before the start of the session. Please call (303)569-2333 ext. 301.
Describe special routine for bedtime/wake-up time at home:___________________________________________________________
__________________________________________________________________________________________________
SOCIAL:
Was applicant ever sent home or denied admission to camp?
___ Yes ___No If yes, please explain:_________________________
__________________________________________________________________________________________________
Has applicant ever been away from home? ___Yes
____ No Explain: _________________________________________
What hobbies/activities does applicant enjoy during free time?_________________________________________________________
List any special behavior problems:_______________________________________________________________________________
__________________________________________________________________________________________________
When do behavior problems occur?_______________________________________________________________________________
__________________________________________________________________________________________
Describe effective methods to control difficult behaviors:______________________________________________________________
__________________________________________________________________________________________________
Is the applicant prone to wandering or running away?
___Yes
___No
In order for the camper to have a successful week at camp, please add any other important information regarding the camper’s
behaviors, preferences or routines and please add any tips for success. ___________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________________
Camper Name: __________________________________________________________________________________________________________ Page 6
INSURANCE: Please attach a copy of Insurance/Medicaid/Medicare card to application.
Is the applicant covered by hospitalization insurance?
___Yes
___No
Carrier:__________________________________
Policy/Group #:____________________________________________
Medicaid #:_______________________________
Medicare #:_______________________________________________
HEALTH INFORMATION AND RESTRICTIONS
Height: _______________
Weight:________________________
Does the applicant have seizures?
___Yes
___Tonic-Clonic (Grand Mal)
___No
___Non-Convulsive (Petit Mal)
___Psychomotor ___Nocturnal
___Mixed
Seizure Frequency: ___________________________________________________________________________________________
Typical Length of Seizure: _____________________________________________________________________________________
Date of Last Seizure: __________________________________________________________________________________________
Describe any warning or aura before a seizure: ______________________________________________________________________
List medications used for seizures:________________________________________________________________________________
ALLERGIES (Please specify)___________________________________________________________________________________
__________________________________________________________________________________________________
Please include any additional health information you feel would be helpful to the medical staff (i.e. shunts): ____________________
____________________________________________________________________________________________________________
VI. MEDICATIONS AT CAMP: Please review carefully.

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All medication, vitamins and supplements not packaged by a pharmacist must be pre-packaged in a
medication cassette and brought to camp with original pharmaceutical packaging and/or bottles. Liquid
medications must be kept in original bottles.
Please include a minimum of one pill in each prescription bottle.
No medications, vitamins, dietary supplements, etc. will be administered without a doctor’s prescription and
the original bottles.
All changes to current prescriptions MUST be in writing with a doctor’s signature. NO medications will be
administered without a doctor’s prescription.
Please call (303) 569-2333 x 301 if you have any questions regarding our medication policies.
Bubble packaging by pharmacy
Medication cassette packaged at home
Must bring original prescription bottles.
Camper Name: __________________________________________________________________________________________________________ Page 7
Children’s Hospital Colorado
Aurora, Colorado
Talking with Technology Camp
Release Form
Camper/Sibling Name: ______________________________________ Date: ______________ _______
This form must be completed for each camper/sibling.
(If the participant is a minor or is unable to consent, complete the following.)
The participant is unable to consent because (a) the participant is a minor, _____ years of age, or (b) other reason
________________________________________. The undersigned, (acting on behalf of all parents and guardians of the
above named participant) certifies that the undersigned is a parent or legal guardian of said participant and has full and
complete authority from said participant's other parent or legal guardians to give the above consent and make the
representations hereunder on their behalf and on behalf of said participant.
X
______________________________
_______________________________
signature of parent/guardian
witness
PHOTO RELEASE: I, the undersigned, hereby grant permission for the taking of pictures and/or release of general
information. This photograph and/or general information may be published in, or used by, any of the media or hospital
publications (including newspapers, magazines, television, radio, pamphlets, brochures, reports), or professional
presentations without any liability on the part of The Children's Hospital, its agents or employees.
X
______________________________
_______________________________
signature of parent/guardian
witness
SPECIAL PROGRAM CONSENT: I, the undersigned, hereby authorize participation of the above named participant in
the special program Talking With Technology Camp, which is organized by the Audiology, Speech Pathology and
Learning Services Department. I hereby release The Children's Hospital, any employee or volunteer of The Children's
Hospital, and/or any participant in the special program named above from any liability whatsoever in connection with this
program.
X
______________________________
_______________________________
signature of parent/guardian
witness
E-Mail: I, the undersigned, hereby give permission for the above participant to access the Internet, under supervision, and
to give his/her e-mail address (if available), and other personally identifying information (such as name, age, information
about his/her disability and AAC system used), to an individual or appropriate group; and/or receive e-mail, in conjunction
with activities during the Talking With Technology Camp program.
X
______________________________
_______________________________
signature of parent/guardian
witness
Participant's e-mail address: _____________________________________________________
Other e-mail addresses to send "letters from camp": ___________________________________
_____________________________________________________________________________
Camper Name: __________________________________________________________________________________________________________ Page 8
EXPLANATION OF CAMP ACTIVITY POLICY
Each camp participant will be given the opportunity to participate in daily camp activities and day-trips. Examples of daily
activities are: arts and crafts, swimming, horseback riding, sports and games, archery, on-camp campouts, and computer
lab. A day-trip is an excursion off camp property which the camper signs up for at camp. Day-trip excursions may include
such challenging activities as river-rafting, river traversing, wilderness camping, touring local history exhibits, and
ascending/descending a climbing tower using climbing gear. Parents or guardians may indicate exclusions below if they
do not wish for their camper(s) to participate in some events. This form must be completed for each camper/sibling.
The Colorado Easter Seal camp program at Rocky Mountain Village is in compliance with all safety standards for
excursions and trip camping as expressed by the American Camping Association. This means that all controlled higherrisk activities meet the safety standards, and all personnel who participate are trained accordingly.
DAY-TRIP RELEASE: I, the undersigned, give this camper permission to participate in day-trips. I understand that this
excursion will involve a trip off camp property and that trained personnel will be present to provide transportation to and
from the day-trip destination.
X
______________________________
_______________________________
signature of parent/guardian
witness
Camp Activity/Day-Trip Exclusions:
I hereby acknowledge and agree that the above named camper will be participating in camping, recreational, and outdoor
activities during the summer camp program at Rocky Mountain Village. I understand that instruction and participation will
be tailored to meet the needs of those who have disabilities. I further understand and acknowledge that the above named
camper may be participating in any, or all, of the activities listed below:
My camper may participate in ALL camp activities
☐
Please check those activities the camper is NOT allowed to participate in.
(See reverse side for a brief description of the programs listed below.)
☐ Arts and Crafts
☐ Computer Lab
☐ Wilderness Camping
☐ On-Camp Campouts
☐ Ropes Course
X
☐ Horseback Riding
☐ Digital Arts and Media
☐ Sports and Games
☐ Climbing Wall
☐ Zip Line
☐ Archery
☐ Swimming
☐ River Rafting
☐ Local Tours
☐ Fishing
______________________________
_______________________________
signature of parent/guardian
witness
(Date)
Return this form to:
Children's Hospital Colorado
Attn: Felicia Hardney, Program Assistant
13123 E 16th Avenue, B030 ASL
Aurora, CO 80045
Fax: 720-777-7878
Email: Felicia.Hardney@childrenscolorado.org
Camper Name: __________________________________________________________________________________________________________ Page 9
Easter Seals – Rocky Mountain Village
Description of Camping and Recreation Activities

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Fishing: Our fishing ponds are stocked by the Colorado Division of Fish and Wildlife. The upper pond has shore
fishing and an accessible dock. Equipment is provided.
Horseback Riding: Our riding program has a therapeutic emphasis. Campers ride one at a time with one person
leading the horse and two people walking along side. If necessary a staff member will ride with the camper. All
rides are conducted in our contained, fully accessible riding arena.
Swimming: Our outdoor swimming pool is kept at 88 degrees, so it is very relaxing for many of our campers.
Recreational activities are provided which include water aerobics, volleyball, basketball, free swim and
relaxation. We also have a hot tub which is kept at 102 degrees.
Recreation: Campers enjoy friendly competition in the outdoors by participating in a variety of games including
kickball, softball, basketball, tennis, parachute games, relays, bowling, etc., with an emphasis on participation
more than winning.
Digital Arts and Media: Using computers and digital devices campers create digital photo albums, PowerPoint
presentations and camp newsletters. Internet searches and email letters may also be included in activities.
On-Camp Campouts: Campers will have the opportunity to sleep in tents, prepare meals on camp stoves and
enjoy an intimate campfire. Campers will be supervised by counseling staff and remain on camp property.
Challenge and Leadership: A series of initiative and team building games are provided using ropes activities
attached to the ground. The activities provide opportunities for campers to develop or improve self-esteem, trust
and decision-making skills.
Climbing Wall: Using ropes, harnesses and a belay system campers can choose to climb three separate walls
challenging all ability levels. Campers are also able to rappel from the top of the tower belayed by trained staff
members. The wall is accessible to all ability levels. A safety belay system is used at all times.
Zip Line: Using ropes, harnesses and a pulley system, campers are hoisted up to the top of a 30-foot tower.
Campers are able to either use their own body strength to ascend or be pulled up by trained staff members. A
safety belay system is also used. Campers are then transferred to the zip line where they are able to zip down a
cable approximately 300 feet to the dismount point.
Off-Camp Wilderness Campouts: Campers will have the opportunity to sleep in tents at an accessible, established
Colorado campground. Interested campers sign-up with staff and a lottery system is used to decide who will go on
the overnight trip.
Off-Camp Day Trips: Trips may include, but are not limited to the following: hiking, fishing, Georgetown Loop
Railroad, mine tours, sports events and picnics. Interested campers sign up on a daily basis, and a lottery system is
used to decide who will go on the trip.
Please feel free to call (303) 569-2333 if you have questions.
Camper Name: __________________________________________________________________________________________________________ Page 10