Heart of Illinois Special Recreation Association
2012 SUMMER CAMPS
REGISTRATIONS WILL BE TAKEN BEGINNING FRIDAY 1/13/12 AND SATURDAY 1/14/12 (SEE BACK PAGE)
Camp Free To Be
Everyone is free to be who they are at Camp Free To Be! Camp Free to Be has a close camper-to-staff ratio. It can be as low as 1:1 and is suitable for children with severe and/ or multiple disabilities. This will ensure your child’s success in the fun camp activities they will encounter. All campers need to bring a sack lunch and drink daily. Age: 4-21 Weekly Fee-R/NR: $115/$142 Locations: Camp Free To Be – Peoria HISRA, 8727 N. Pioneer Rd, Peoria, IL Day/Time: Monday through Friday, 8:30am-4:00pm Week #1 #2 #3 #4 #5 #6 #7 #8 #9 #10
Dates 6/11-6/15 6/18-6/22 6/25-6/29 7/2-7/6 7/9-7/13 7/16-7/20 7/23-7/27 7/30-8/3 8/6-8/10 8/13-8/17
Peoria Code 50579 50580 50581 50582 50583 50584 50585 50586 50587 50588
Weekly Fee-R/NR $115/$142 $115/$142 $115/$142 $88/$112 $115/$142 $115/$142 $115/$142 $115/$142 $115/$142 $115/$142
Camp Free To Be – Washington Washington Park District, 105 S. Spruce St, Washington, IL Day/Time: Monday through Friday, 8:30am-4:00pm Week #1 #2 #3 #4 #5 #6 #7 #8 #9 #10
Dates 6/11-6/15 6/18-6/22 6/25-6/29 7/2-7/6 7/9-7/13 7/16-7/20 7/23-7/27 7/30-8/3 8/6-8/10 8/13-8/17
Washington Code 50568 50569 50570 50571 50572 50573 50574 50575 50576 50577
In need of door-to-door transportation? Contact the appropriate company: • City of Peoria: CityLift 999-3667 • Peoria County: Rural Peoria County 697-3305 • Morton: We Care, Inc. 263-7708
Weekly Fee-R/NR $115/$142 $115/$142 $115/$142 $88/$112 $115/$142 $115/$142 $115/$142 $115/$142 $115/$142 $115/$142
Note: There will be no camps on July 4, 2012 Camp Connections
Camp Connections is a summer camp program designed to offer fun camp activities which will help children with Autism Spectrum Disorders (ASD) and other developmental disabilities acquire important social skills that can stand alone or be combined with other camp programming. This program will be staffed with a Certified Special Education Teacher and can be used as an Extended School Year option. All participants will have many opportunities to practice their social and communication skills. The program’s aim is to help campers to improve their ability to interact with others, increase understanding of others and respect for individual differences, and overall, provide a fun and supportive camp-based opportunity to practice these skills. The program will offer individual instruction, large and small group lessons, and other socially engaging activities. Camp staff will use a combination of evidencebased strategies including positive reinforcement, videomodeling, observational learning, social listener training, and other naturalistic teaching approaches to help the participants experience success. To monitor individual progress, data will be collected and analyzed on a daily basis. Age: 4-21 Dates: Monday-Friday, June 18-Aug. 10 Locations: Camp Connections – Peoria HISRA, 8727 N. Pioneer Rd, Peoria, IL Dates 6/18-8/10
Time 9:00am-11:00am
Peoria Code 50599
Fee-R/NR $850/$950
Camp Connections - Washington Washington Park District, 105 S. Spruce St, Washington, IL Dates 6/18-8/10
Time 1:00pm-3:00pm
Wash. Code 50609
Fee-R/NR $850/$950
Summer Daze
Summer Daze is a fun way to stay active this summer. We will explore the Central Illinois area for fun and adventure! This camp is designed with some eligibility restrictions, due to the nature of the camp. Please speak with a Program Supervisor about camp eligibility. Space is limited, so sign up early. A detailed schedule will be provided each week to help you plan for the upcoming week. Be sure to bring a sack lunch and drink each day! Age: 13-21 Day/Time: Monday through Thursday, 9:00am-4:00pm June 18 - August 9 Location: HISRA Week #1 #2 #3 #4 #5 #6 #7 #8
Dates 6/18-6/21 6/25-6/28 7/2-7/5 7/9-7/12 7/16-7/19 7/23-7/26 7/30-8/2 8/6-8/9
Code 50666 50667 50668 50669 50670 50671 50672 50673
Weekly Fee-R/NR $115/$142 $115/$142 $86.25/$106.50 $115/$142 $115/$142 $115/$142 $115/$142 $115/$142
Afternoon Fun
(Formerly “Morton In Motion”) Looking for something fun to do after summer school this summer? This year we will be offering the opportunity for you to join in with HISRA’s newest camp, being offered at the Washington Park District Building. You will participate in traditional camp activities, like arts and crafts and games! This camp will be held in Washington and after care options are available on a limited basis. Age: 4-21 Day/Time: Monday through Friday, 12:00pm-4:00pm Location: Washington Park District Building Week #1 #2 #3 #4 #5 #6 #7 #8
Dates 6/11-6/15 6/18-6/22 6/25-6/29 7/2-7/6 7/9-7/13 7/16-7/20 7/23-7/27 7/30-8/3
Code 50619 50620 50621 50622 50623 50624 50625 50626
Weekly Fee-R/NR $60/$75 $60/$75 $60/$75 $48/$60 $60/$75 $60/$75 $60/$75 $60/$75
Extended Care for Camp
Are you looking for extended care before and after camp in order to fit your schedule? HISRA has what you are looking for! Morning extended care is available from 7:30-8:30 a.m. and evening extended care from 4:00-5:00 p.m. Sign up by week # as needed. Age: 4-21 Day/Time: Monday through Friday, 7:30am-8:30am and 4:00pm-5:00pm Locations: Extended Care – Peoria HISRA, 8727 N. Pioneer Rd, Peoria, IL Week #1 #2 #3 #4 #5 #6 #7 #8 #9 #10
Dates 6/11-6/15 6/18-6/22 6/25-6/29 7/2-7/6 7/10-7/13 7/16-7/20 7/23-7/27 7/30-8/3 8/6-8/10 8/13-8/17
Peoria Code 50589 50590 50591 50592 50593 50594 50595 50596 50597 50598
Weekly Fee-R/NR $20/$25 $20/$25 $20/$25 $16/$20 $20/$25 $20/$25 $20/$25 $20/$25 $20/$25 $20/$25
Extended Care – Washington Washington Park District, 105 S. Spruce St, Washington, IL Week #1 #2 #3 #4 #5 #6 #7 #8 #9 #10
Dates 6/11-6/15 6/18-6/22 6/25-6/29 7/2-7/6 7/10-7/13 7/16-7/20 7/23-7/27 7/30-8/3 8/6-8/10 8/13-8/17
Washington Code 50568 50569 50570 50571 50572 50573 50574 50575 50576 50577
Weekly Fee-R/NR $20/$25 $20/$25 $20/$25 $16/20 $20/$25 $20/$25 $20/$25 $20/$25 $20/$25 $20/$25
REGISTRATION FORM 2012 SUMMER CAMPS Heart of Illinois Special Recreation Association • 8727 N. Pioneer Rd. Peoria, IL 61615 • Phone: (309) 691-1929
WAIVER: (MUST be signed for
Full Name of Participant: Birthdate:
/
/
Age:
participation)
Male/Female (CIRCLE)
Parent/Guardian Full Name: Address: City, State, ZIP: Phone: Disability:
PAYMENT:
ALL registrations MUST be signed and accompanied by payment in order to be processed.
Check Cash Master Card Visa Discover Credit Card Number
Requesting Scholarship Third-Party Payor _______________________________ Payment Plan Signature:
––– Exp:
Camp Free to Be – Peoria Week
Dates
Code
#1
6/11-6/15
50579
$115/$142
Camp Connections
#2
6/18-6/22
50580
$115/$142
Washington
#3
6/25-6/29
50581
$115/$142
Afternoon Fun
#4
7/2-7/6
50582
$88/$112
Week
Dates
Code
#5
7/9-7/13
50583
$115/$142
#1
6/11-6/15
50619
$60/$75
#6
7/16-7/20
50584
$115/$142
#2
6/18-6/22
50620
#7
7/23-7/27
50585
$115/$142
#3
6/25-6/29
#8
7/30-8/3
50586
$115/$142
#4
#9
8/6-8/10
50587
$115/$142
#5
#10
8/13-8/17
50588
$115/$142
Peoria
Signature of Participant or Parent/Guardian
Date
Extended Care – Peoria
Camp Connections X Fee-R/NR
As a participant, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, including death, damages, or loss which I may sustain as a result of participating in any and all activities connected with or associated with such program. I agree to waive and relinquish all claims I may have as a result of participating in the program against the Heart of Illinois Special Recreation Association and its officers, agents, servants, and employees. I do hereby fully release and discharge the Heart of Illinois Special Recreation Association and its officers, agents, servants, and employees from any and all claims from injuries, including death, damage, or loss which I may have or which may accrue to me on account of my participation in the program. I further understand and agree that the terms such as“participating,”“programs,”and “activities,” referred to in the Agreement, include all exercises and physical movements of any nature while I am participating in these programs and further include the provision of or failure to provide proper instructions or supervision, the use and adjustment of any and all machinery, equipment, and apparatus, and anything related to my use of the services, facilities, or premises involved in these programs, and transportation to and from any events. I authorize HISRA staff to dispense prescribed medications in their original container or accompanied by a copy of a signed prescription to me/my child. I understand the nature of these programs for which I am registering, and fully understand this Waiver, Release, and Hold Harmless Agreement. I further understand that any advisements or warnings of the particular risks of these programs that I subsequently receive will be incorporated by reference into and become a part of this Agreement. Additionally, in order that the Heart of Illinois Special Recreation Association may better serve the interests of myself/my child, I hereby grant permission for Special Recreation staff to access relevant education and/or medical records. I hereby consent to the use of my/my child’s photograph in the Heart of Illinois SRA brochures, publications, or promotional materials.
50599
$850/$950
Week
Dates
Code
X Fee-R/NR
#1
6/11-6/15
50589
$20/$25
#2
6/18-6/22
50590
$20/$25
#3
6/25-6/29
50591
$20/$25
#4
7/2-7/6
50592
$16/$20
#5
7/10-7/13
50593
$20/$25
$60/$75
#6
7/16-7/20
50594
$20/$25
50621
$60/$75
#7
7/23-7/27
50595
$20/$25
7/2-7/6
50622
$48/$60
#8
7/30-8/3
50596
$20/$25
7/9-7/13
50623
$60/$75
#9
8/6-8/10
50597
$20/$25
#6
7/16-7/20
50624
$60/$75
#10
8/13-8/17
50598
$20/$25
Camp Free to Be – Washington
#7
7/23-7/27
50625
$60/$75
Extended Care – Washington
Week
#8
7/30-8/3
50626
$60/$75
Week
X Fee-R/NR
50609
Dates
Code
#1
6/11-6/15
50568
$115/$142
Summer Daze
#2
6/18-6/22
50569
$115/$142
Week
Dates
Code
#3
6/25-6/29
50570
$115/$142
#1
6/18-6/21
50666
#4
7/2-7/6
50571
$88/$112
#2
6/25-6/28
#5
7/9-7/13
50572
$115/$142
#3
#6
7/16-7/20
50573
$115/$142
#4
#7
7/23-7/27
50574
$115/$142
#8
7/30-8/3
50575
#9
8/6-8/10
#10
8/13-8/17
$850/$950 X Fee-R/NR
Dates
Code
X Fee-R/NR
#1
6/11-6/15
50568
$20/$25
#2
6/18-6/22
50569
$20/$25
$115/$142
#3
6/25-6/29
50570
$20/$25
50667
$115/$142
#4
7/2-7/6
50571
$16/$20
7/2-7/5
50668
$86.25/$106.50
#5
7/10-7/13
50572
$20/$25
7/9-7/12
50669
$115/$142
#6
7/16-7/20
50573
$20/$25
#5
7/16-7/19
50670
$115/$142
#7
7/23-7/27
50574
$20/$25
$115/$142
#6
7/23-7/26
50671
$115/$142
#8
7/30-8/3
50575
$20/$25
50576
$115/$142
#7
7/30-8/2
50672
$115/$142
#9
8/6-8/10
50576
$20/$25
50577
$115/$142
#8
8/6-8/9
50673
$115/$142
#10
8/13-8/17
50577
$20/$25
X Fee-R/NR
HEART OF ILLINOIS SPECIAL RECREATION ASSOCIATION (HISRA) 2012 ANNUAL INFORMATION FORM
FOR OFFICE USE ONLY:
PLEASE PRINT - PLEASE DO NOT ABBREVIATE The Annual Information Form MUST be filled out completely, returned to HISRA and on file prior to attendance in programs. Please provide as many details as possible. If a question is not applicable, please indicate with N/A on the appropriate line. HISRA staff may call to clarify or ask for further information. This form is taken to all programs and trips by HISRA staff.
PARTICIPANT INFORMATION NAME: ADDRESS: CITY/ZIP CODE: HOME PHONE NUMBER: WORK PHONE NUMBER: CELL PHONE NUMBER: MALE or FEMALE DATE OF BIRTH: AGE: AGENCY INVOLVED: SCHOOL: PRIMARY DISABILITY:
PARENT/GUARDIAN INFORMATION (indicate self) NAME: ADDRESS: CITY/ZIP CODE: HOME PHONE NUMBER: WORK PHONE NUMBER: CELL PHONE NUMBER: LOCAL EMERGENCY CONTACT PERSON (OTHER THAN PARENT/GUARDIAN) NAME: RELATIONSHIP: HOME PHONE NUMBER: WORK PHONE NUMBER: CELL PHONE NUMBER:
N/A N/A
PLEASE COMPLETE THE FOLLOWING:
SECONDARY DISABILITY (IF ANY): DOES PARTICIPANT HAVE SEIZURES? PETITE MAL GRAND MAL
YES
ALL PARTICPANT’S ALLERGIES (INCLUDING FOODS TO AVOID):
NO
N/A IF OF LEGAL DRINKING AGE, IS PARTICIPANT ALLOWED TO CONSUME ALCOHOL? YES NO N/A ALL PARTICIPANT’S MEDICATIONS (INCLUDING TIMES, DOSAGES, DETAILS):
DATE OF LAST SEIZURE, FREQUENCY, LENGTH: N/A DOES THE PARTICIPANT LOSE CONSCIOUSNESS DURING A SEIZURE? YES NO N/A
N/A MAJOR ACCIDENTS OR INJURIES IN THE PAST YEAR THAT COULD AFFECT PARTICIPANT’S ACTIVITY:
Are there any warning signs when a participant is about to have a seizure? YES NO (if yes, please list them) N/A IS THERE ANY SPECIAL CARE NEEDED WHEN THE PARTICIPANT HAS A SEIZURE? YES NO (if yes, please be specific as possible) N/A DESCRIBE TYPICAL SEIZURE ACTIVITY:
N/A SWIMMING ABILITY OF PARTICIPANT Needs full assistance while swimming Has some swimming skills (floats, puts head under water) Knows and can perform some strokes Can swim independently Name of person filling out form:
N/A HOW OFTEN DOES THE PARTICIPANT HAVE SEIZURES?
Phone Number:
N/A Return form to HISRA, 8727 N. Pioneer Road, Peoria, IL 61615. FAX: (309) 691-4383 Please call (309) 691-1929 if you have questions.
NAME: PARTICIPANT’S DAILY LIVING SKILLS DIETARY NEEDS: Participant can eat independently Participant uses adaptive equipment (please explain): Participant needs help when eating (please explain): DIET INSTRUCTIONS: None Puree Mechanical Soft Other: ADDITIONAL SPECIAL DIETARY INSTRUCTIONS (i.e. needs straw, etc.): TOILETING: Participant can manage to toilet self independently: Participant needs escort or assistance with toileting: If yes, please explain:
YES YES
No No
MOBILITY: DOES PARTICIPANT USE ANY OF THE FOLLOWING: YES No LEG BRACES CRUTCHES CANE MANUAL WHEELCHAIR ELECTRIC WHEELCHAIR OTHER (please specify): (IF PARTICIPANT IS IN A WHEELCHAIR): YES No IS PARTICIPANT WEIGHT BEARING? CAN PARTICIPANT TRANSFER FOR TRANSPORTATION? YES NO 1 person assist 2 person transfer WHEN TRANSFERRING, DOES PARTICIPANT NEED: COMMUNICATION SKILLS: (please check all that apply) Understands what is said to him/her Can express needs Has difficulty expressing needs Speaks clearly Speech is difficult to understand at times Uses sign language Uses communication device/board SOCIAL SKILLS: What might upset or frustrate participant? Other (please explain):
OTHER MEANS OF COMMUNICATION: (please check all that apply) Cries Screams Takes person to location Moves person’s hand Grabbing Gestures/Points Shakes head Loud noises
Physical touch
How does participant behave when upset or frustrated? (please explain) How do caregivers respond/what do they say when this behavior occurs? (please explain) How does participant behave when happy? (please explain) Does participant need redirection to stay with group?
YES
No (If YES please explain)
Please explain any other habits/behavior patterns staff should be aware of: Does participant use a behavior plan?
YES
No (If YES please provide HISRA a copy of the plan)
What programs/skills, if any, is the participant working on? (please explain) Return form to HISRA, 8727 N. Pioneer Road, Peoria, IL 61615. FAX: (309) 691-4383 Please call (309) 691-1929 if you have questions.
Heart of Illinois Special Recreation Association 8727 North Pioneer Road, Peoria, IL 61615 Phone: 309-691-1929, Fax: 309-691-4383 hisra@peoriaparks.org PERSONAL CARE REQUEST FORM IMPORTANT INFORMATION: Heart of Illinois Special Recreation Association (“HISRA”) is committed to complying with the Americans With Disabilities Act (the “ADA”) and providing reasonable modification/accommodation. Parents and guardians requesting personal services/care for their child/ward must understand and appreciate that many personal services are outside the scope of the ADA. HISRA reviews requests for personal care/services on a case-by-case basis. HISRA’s handbook identifies certain personal care/services that are not provided by HISRA staff. At times, HISRA will voluntarily provide personal care/services that are outside the scope of the ADA. Various factors are taken into account, including, but are not limited to: staff resources, experience and expertise; the potential impact on the staff/participant ratio; the safety of the participant; physician authorization and approval; and other such pragmatic considerations.
NAME OF PARTICIPANT: Please list any and all personal services/care requests. Kindly understand that HISRA does not guarantee that it can comply with any specific request/need. Please use additional sheet of paper if necessary. Please check all that apply and provide detailed information of each need: Medication Dispensing Toileting Assistance Feminine Care Assistance Epinephrine injections Inhaler Assistance Feeding Tube Management Diazepam Rectal Gel Delivery Suction Device Management Catheter Management IV Medications Tracheotomy Management Nebulizer Therapy Vagal Nerve stimulator Insulin Pump Management Syringe Injections (insulin/other) Seizure Treatment Other:
BILLING STATEMENTM:\KKOLTON\HISRA\2012 CAMP BROCHURE\PERSONAL CARE REQUEST FORM.DOC UPDATED: 12/1/2011
A cooperative extension of the Chillicothe, Morton, Washington and Peoria Park Districts providing quality recreation programs and services to individuals with disabilities.
PRSRT STD U.S. Postage PAID Permit No. 247 Peoria, IL
Heart of Illinois Special Recreation Association 8727 N. Pioneer Rd. Peoria, IL 61615 Call 691-1929 or Fax 691-4383 http://www.peoriaparks.org/heart-of-illinois-special-recreation OFFICE HOURS Mon - Fri, 8:00 am - 12:00 pm & 1:00 pm - 4:30 pm Closed 1/2 and 1/16
OR CURRENT RESIDENT
SUMMER CAMP 2012 REGISTRATION FAIR On January 13 and 14, 2012, HISRA will begin taking registrations for Summer Camp 2012. FRIDAY 1/13/12 FROM NOON TO 7:00 PM AND SATURDAY 1/14/12 FROM 8:00 AM TO NOON If you are unable to come in to register your camper during the Summer Camp 2012 Registration Fair, please come into HISRA during office hours (Monday through Friday, 8:00am-noon and 1:00-4:30pm) after 1/13/12 to register. If you are unable to come into HISRA during office hours, please contact Jennifer at 691-1929 to set up an appointment. Open camp registration will continue until May 1, 2012 Registrations will be taken on a first-come, first-served basis. Walk-in registrations will be processed at that time.
THE FOLLOWING PAPERWORK MUST BE COMPLETED IN ORDER FOR A REGISTRATION TO BE ACCEPTED AND PROCESSED: 1. Registration Form 2. 2012 Annual Information Form 3. Personal Care Request 4. Payment Arrangements with deposit