Specialized Programs
SUMMER 2014
for Adults with Disabilities
Explore More
Specialized Programs 4554 NE 41st Street Seattle, WA 98105
Dear Recreation Enthusiast, Summer is our favorite time of year at Seattle Parks and Recreation. It’s when throngs of Seattle-ites fill our parks with picnics, pick-up ball games, laughing children, long walks, weddings, lazy days at the beach and so much more. This year as summer comes around, we at Seattle Parks have our minds on some serious business: continuing to fund the parks, programs and services that Seattle-ites know and love. We have spent the past two years planning for a vibrant future of our park system with the development of the Parks Legacy Plan. This is a guiding document that helps us plan for the future of Seattle’s public parklands and facilities. We have developed this with significant input from residents who use our parks, programs and facilities. We used the document as the basis for a possible park funding measure that may go in front of voters later this year. We have held a series of public meetings to inform the community about the plan and get feedback from residents. Just about the time this brochure goes to print, the Mayor- and Council-appointed Parks Legacy Plan Citizens’ Advisory Committee will be making its final recommendations on the size and type of funding package. The Mayor and Council will take further public input before determining what will go before voters. If you’d like to learn more about Legacy Plan, or the status of the proposed funding ballot measure, please visit our website at www.seattle.gov/parks/legacy/committee.htm. Sincerely, Christopher Williams Acting Superintendent
Your Advisory Council Most classes, workshops, sports programs, special events and facility rentals are funded through the local advisory council, rather than from City of Seattle budgets. Revenues generated through program fees offset program costs to make these activities self-sustaining. We also rely on participation, donations, and contributions to maintain and upgrade equipment. Advisory council members create scholarship opportunities through grant writing and other fundraising activities. Join Us! Citizen direction and participation is essential to our success. The Specialized Programs Advisory Council is in its 45th year of operation and invites you and your family to enjoy recreation activities offered. If you would like to help other like-minded citizens and professional Specialized Programs staff to support, advocate and fundraise for these important programs, we invite you to apply to join the advisory council. The advisory council meets on the third Wednesday at 6:30 pm. For further information call Tim Pretare at 206-615-0140.
Specialized Programs Adult Summer 2014
2
SPECIALIZED PROGRAMS Adult Summer Activities 2014 Professional Staff Christopher Williams, Acting Superintendent Kelly Guy, Director of Recreation Brenda Kramer, Manager, Special Populations Tim Pretare, Coordinator, Specialized Programs Linda Guzzo, Administrative Specialist I
Recreation Staff Tori Fernau, Adult Recreation Specialist Jayson Powell, Recreation Leader Iris Swisshelm, Recreation Attendant
Program Information Our goal is to provide recreational opportunities for people who choose to participate in activities designed and conducted by trained staff. If you have any questions on programs listed in this brochure or need further information, please call our office at 206-684-4950. Fees and Charges The programs and activities listed in this brochure are provided by the Specialized Programs Advisory Council under an agreement with Seattle Parks and Recreation. Fees collected are used to offset the cost of providing programs. 12% of each program registration fee is used to defray overhead costs and 88% is related to the direct cost of providing the program. Class and program fees include WA state sales tax where applicable. Disclaimer Although we strive to be accurate, this brochure is published for information purposes only. Seattle Parks and Recreation reserves the right to make any changes in the content, fees, and provisions of the brochure without notice. Visit www.seattle.gov/parks for updated information. Refund Policy It is the policy of Seattle Parks and Recreation and the Associated Recreation Council that: Anyone who registers for a class, special event or program that is cancelled for any reason by Parks and Recreation will receive a full refund. Anyone who registers for a trip, special event, or facility rental, and who requests a refund 14 days or more before its start (or before the second session of a class), may receive a refund minus a service charge. Anyone who registers for a trip, special event, or facility rental, and who withdraws from the activity fewer than 14 days before its start (or after the second session of a class), will receive no refund.
Persons with Disabilities Reasonable accommodations will be made on request for persons with disabilities. If you need sign language interpretation, auxiliary aids, or other accommodations, please call 206-684-4950 or (TDD only, 206-684-4950). PLEASE ALLOW TEN WORKING DAYS ADVANCE NOTICE FOR SIGN LANGUAGE INTERPRETATION OR AUXILIARY AIDS. If a class or activity is scheduled in an area that is not barrier free for wheelchairs, we will make every effort to help you find a similar program in an accessible location. Anti-discrimination As a matter of policy, law, and commitment, Seattle Parks and Recreation does not discriminate on the basis of sexual orientation, political ideology, age, creed, religion, ancestry, national origin, or presence of any sensory, mental, or physical handicap. (Seattle Municipal Code 18.12.180) Specialized Programs Adult Summer 2014
3
Information Regarding ACCESS Transportation Services We have had increasing numbers of participants coming to and from programs via Access Service. Due to this increase, issues have been raised that we would like you to be aware of when making arrangements for Access rides. 1. Each program in our brochure has a stated Access “drop-off appointment time” and a “pickup window”. When you schedule your rides, please request only these stated times! Please note Access has “drop-off windows” and they have “dropoff appointment times”. Please use only the “drop off appointment times” for our programs. 2. Please remember, if a participant arrives too early, the facility may not be open or Specialized Programs staff may not have arrived yet. If a participant’s pick-up window is scheduled late, it will affect programs that follow.
Did You Know?
3. When you register for programs, please state if the participant will be using Access to and/or from program.
Subscription Service
4. If there is a consistent problem with early drop-off appointments or late pick-ups, we will call you to discuss the situation.
This service is great when a participant wants to set up a ride to the same destination, at the same time, every week. Please state that you are going to a Seattle Parks and Recreation Program, and it can be set up for you immediately.
Services Offered by ACCESS
5. If you have any questions about our specific Access appointment times or pick-up windows, please call Specialized Programs at 206-684-4950.
Door-to-Door The driver will walk the participant to the doorway of the destination.
6. If you have problems with the Access Service, please call Access at 206-205-5000 (TTY 206-7494286) and talk with their Customer Service staff.
Hand-to-Hand The driver must deliver the participant to the appropriate person at the destination. If you use this service, please have participants locate “Specialized Programs Staff”. To apply for these services, please contact Access Customer Service at 206-205-5000 (TTY 206-7494286).
Specialized Programs Adult Summer 2014
4
c
ADULT SPECIALIZED PROGRAMS
Table of Contents What’s Cooking
6
Try New Things (TNT) Club
7
Softball Information
8
Summer Sightseeing
9
Golf
10
Starlight Social
11
Southend Social
11
Walking Trips
12
Camp Long Information
13-14
Participant Information Form
15-20
DDD / Scholarship Information
21
Iris Swisshelm
Duncan Award Recipient Congratulations Iris ! The prestigious Duncan Award is given each year by Children’s Hospital to acknowledge parents, professionals or groups who have made a significant contribution to the well-being of children with disabilities within Washington State. Recipients of the Duncan Award demonstrate an extraordinary positive social or scientific impact on the well-being of children with disabilities above and beyond usual career expectations. Since 1969, Iris has truly made a difference in our Specialized Programs Section, touching the lives of countless participants, parents, staff and volunteers through her fun sense of humor, her selfless dedication, extensive knowledge, and continuing commitment. Iris considers it just doing her job, but she does that and so much more. Congratulations, again, to Iris, who is someone so deserving of this prestigious recognition.
Saturday Travels (not held summer quarter)
Safety and Behavior Policy Ensuring safety for all of our participants is our top priority. Any participant conduct that is disruptive or unsafe in programs / camps, to fellow participants, campers, volunteers, or staff may result in being sent home early that day, unable to attend for a specified amount of time, or unable to attend on a permanent basis. This will be decided on a case-by-case basis and is at the discretion of the leadership staff. Such conduct includes, but is not limited to: destruction of property, harming oneself or another person, or refusal to follow the minimum safety requirements to participate in activities. All incidents will be documented and reported to direct caregivers in a timely manner.
Specialized Programs Adult Summer 2014
5
Cooking Class Cooking Class is for adults 18 years of age and older, who are independent, follow directions easily, and do not require one-on-one supervision. Learn basic skills for preparing and cooking healthy meals from beginning to end and enjoy eating our finished meals. Due to the popularity of this program and the limited number of people we can accommodate, we request agencies / group homes limit to two the number of adults they register. Dates:
Mondays - See below for the sessions offered
Time:
6:30-8 p.m.
Cost:
$25 per session due by Friday, June 13 You may pay with a credit card or you can make your check payable to: City of Seattle If paying with check, please mail to: Specialized Programs, 4554 NE 41st St, Seattle 98105
Access:
Drop-Off Appointment Time: 6:45 p.m. Pick-Up Window: 8-8:30 p.m.
Registration:
Begins 8 a.m. on Tuesday, June 3 by calling 206-684-4950. Remember to state which session you are registering for, if you will be taking Access, and if you’re using DDD funds.
Note:
You may register for one session and be placed on the wait list for the other session.
Class Sessions Session #1
Delridge Community Center, 4501 Delridge Way SW, 98106
Dates:
June 23, 30 and July 7, 14
__________________________________
Session #2
Northgate Community Center, 10510 – 5th Ave NE, 98125
Dates:
July 28 and August 4, 11, 18
Specialized Programs Adult Summer 2014
6
Try New Things (TNT) Club “TNT Club” is a program for adults with disabilities, 18 years or older who meet weekly to enjoy fun activities including games, movies, crafts, cooking and much more. Please always bring a sack lunch and drink each week. Due to the popularity of this program, we offer two locations for TNT Club. They will do the same activities on different days of the week. Registration for each location will be limited to 40 participants. Please register for just one.
NORTHEAST LOCATION
NORTHWEST LOCATION
Dates: Tuesdays, June 17 – August 19 Time: 10:30 a.m.–1 p.m.
Dates: Thursdays, June 19 – August 21 Time: 10:30 a.m.–1 p.m.
Meadowbrook Community Center 10517 – 35th Ave NE, 98125
Bitter Lake Community Center 13035 Linden Ave N, 98133
Cost:
$15 for summer quarter due by Friday, June 13 You may pay with a credit card or make your check payable to: City of Seattle If paying with check, please mail to: Specialized Programs, 4554 NE 41st St Seattle 98105
Access:
Drop Off Appointment Time: 10:45 a.m. Pick-Up Window: 12:45-1:15 p.m.
Registration:
Register by calling Specialized Programs, 206-684-4950, beginning at 8 a.m. on Thursday, May 29. Be sure to state which session you will be attending – you can only attend one. Please indicate at this time if you will be riding Access or using DDD funds.
REMINDER: The community centers do not open until 10 a.m. and the Specialized Programs staff does not arrive until 10:15 a.m. Please DO NOT request your Access appointment time any earlier than 10:45 a.m. Thank you.
Specialized Programs Adult Summer 2014
7
Softball For adults with disabilities ages 18 and older. Join us for a night of softball! No matter what your ability: a pro, new to the sport, t-ball, or individual skills - we have an event for you! It’s a great way to see your friends and get some exercise. Date:
Tuesdays, June 17 – August 19
Time:
6:30 - 8 p.m.
Cost:
Free
Location:
Northgate Elementary 11725 – 1st Avenue NE Seattle, 98125
Access:
Drop-Off Appointment Time: 6:45 p.m. Pick-Up Window: 8-8:30 p.m.
Open Registration:
Register by calling Specialized Programs at 206-684-4950. Please indicate if you will be riding Access.
Registration and current Special Olympics paperwork due by Tuesday, June 17, to be eligible to compete in the regional and state tournaments.
Important Dates: June 17, Tuesday Pre-register and have your current Special Olympics paperwork turned in to the Specialized Programs Office July 26, Saturday Special Olympics Regional State Tournament in Issaquah August 16-17, Saturday & Sunday Special Olympics State Tournament in Everett Coaches will keep you informed when further information on Regional and State Meets is available
NOTE:
Unless there has been a continuous hard rain, practice will be held. Please do not call before 4:30 p.m., as cancellations will not be determined until that time.
Specialized Programs Adult Summer 2014
8
Summer Sightseeing Join us as we explore Seattle and our neighboring cities on summer sightseeing trips. Please bring a sack lunch and drink. Date: Time: Cost: Meet:
Wednesdays, dates listed below 10 a.m. – 3:30 p.m. Bring cash on day of outing – check each activity for cost. Densmore Building, 8061 Densmore Ave N, Seattle 98103
Access:
Drop-Off Appointment Time: 10 a.m. Pick-Up Window: 3:30-4 p.m.
Registration:
Register by calling Specialized Programs, 206-684-4950, beginning at 8 a.m. on Wednesday, June 4. You may choose 2 trips and be on the wait list for the others. Please indicate if you will be riding Access.
Activities & Dates: July 2 Free
Woodland Park Zoo: Lions, tigers and bears – oh my, plus elephants, penguins, monkeys and more! Wear your walking shoes, as we’ll be on our feet most of the day visiting the animals.
July 9 $10
Putt Putt Golf: Practice your short game at the putt putt course with your friends. Afterwards we’ll head to the park to enjoy our sack lunches.
July 30 Free
Beach Day: Bring your towel and swimsuit as we’ll be hanging out at the beach today – go for a dip, play games, build sand castles! Please bring sun screen and a hat.
Aug 13 $5
Snoqualmie Gourmet Ice Cream Shoppe: Work up an appetite playing games at the park then cool off with a yummy treat at the Snoqualmie Gourmet Ice Cream Shoppe in Maltby.
Aug 20 $15
Nature Walk & Out to the Movies: Head out for a beautiful nature walk, at least one mile over various terrain, then cool off inside watching a recent release at the movie theater. Please bring extra money if you want to purchase snacks at the theater
Specialized Programs Adult Summer 2014
9
Golf Learn to golf from the pros at Jackson Park Golf Course! Everyone can learn to golf, whether you are a beginner or Experienced. We encourage all levels to join us at this fun program. Professional golf instructors will work with our Group, and all equipment will be provided. This quarter, golfers will be given the choice to compete in a Special Olympics tournament. You do not have to compete to participate in this program. Participants must be independent and not require 1:1 supervision. Please wear tennis shoes and weather-appropriate clothing – we will be inside and outside. Unless there has been a continuous hard rain, program will be held. Date:
Wednesdays, June 4 – August 20
Time:
6 – 7:30 p.m.
Cost:
Free
Location:
Jackson Park Golf Course; meet at the Pro Shop 1000 NE 135th Street, Seattle 98125
Access:
Drop-Off Appointment Time: 6 p.m. Pick-Up Window: 7:30-8 p.m.
Open Registration:
Register by calling Specialized Programs, 206-684-4950. Please indicate if you will be riding Access. Please let us know when you pre-register if you would like to compete in Special Olympics or not. Thank you.
Important Dates if Competing in Special Olympics: June 4, Wednesday
Register and have your current Special Olympics paperwork turned in to the Specialized Programs Office
July 27, Sunday
Special Olympics Regional Golf Tournament in Tacoma
August 16 or 17, weekend
Special Olympics State Tournament, location TBA
Coaches will keep you informed when further information on Regional and State meets is available. ** Please note: you can only compete in one Special Olympics sport per season. ** You cannot compete in both softball and golf – you will have to pick one. Specialized Programs Adult Summer 2014
10
Open Registration: Register by calling Specialized Programs, 206-684-4950 for the Starlight Social and Southend Social programs. Please note when you register if you will be taking Access.
Starlight Social This is a fun weekly social program for adults ages 18 and older. Date:
Wednesdays, June 18 – August 13
Time:
6:30 - 8 p.m.
Location:
Miller Community Center, 330-19th Ave East, Seattle, 98112
Cost:
Free
Access:
Drop-Off Appointment Time: 6:45 p.m. / Pick-Up Window: 7:45-8:15 p.m.
Activities & Dates: June 18 June 25 July 2 July 9 July 16
Bingo Games & Puzzles Fourth of July Crafts Trivia Outdoor Games
July 23 July 30 August 6 August 13
Talent Show Bubbles & Chalk Art Movie Night Sock Hop
Southend Social A fun weekly social program for adults ages 18 and older. Date:
Thursdays, June 19 – August 21
Time:
6:30 - 8 p.m.
Location:
Southwest Community Center, 2801 SW Thistle St, Seattle 98126
Cost:
Free
Access:
Drop-Off Appointment Time: 6:45 p.m. Pick-Up Window: 7:45-8:15 p.m.
Activities & Dates:
June 19 June 26 July 3 July 10 July 17
Craft Night Active Games July 4th Activities Bingo Talent Show
Specialized Programs Adult Summer 2014
July 24 July 31 August 7 August 14 August 21
11
Sand Art Cooking Night Games & Puzzles Popsicles and Cool Activities End of Summer Party
Walking Outings This walking program is for individuals who can walk independently without requiring one-on-one supervision. Individuals must be able to walk long distances (not to exceed 3 miles) over a variety of terrain. This program is not wheelchair accessible. Please wear good walking shoes and bring a sack lunch and drink. Date:
Fridays, dates listed below
Time:
10 a.m. – 3:30 p.m.
Cost:
Free
Meet:
Densmore Building 8061 Densmore Ave North Seattle 98103
Access:
Drop-Off Appointment Time: 10 a.m. Pick-Up Window: 3:30-4 p.m.
Registration: Register by calling Specialized Programs, 206-684-4950, starting at 8 a.m. on Thursday, June 5. You may choose 2 trips and be on the wait list 1 other. Please indicate when you register if you will be riding Access. Activities & Dates: August 29:
Discovery Park – Come with us as we visit Seattle’s largest park – 500 acres ! Our day will be filled with flowers, meadows, eagle sightings and a walk on the beach. Rated: medium (due to distance), flat with some paved areas, 3 miles.
Sept. 5:
St. Edwards & Hamlin Parks – Beat the heat and come cool off with us under the shade of beautiful trees. Rated: medium, dirt, some hills, 2.5 miles.
Sept. 19:
Alki Beach and Lincoln Park – Head over to West Seattle to walk on the beach and breathe in the salt air - then head to Lincoln Park for lunch and more exploring. Rated: easy, flat, sand, gravel, 2.5 miles.
NO SATURDAY TRAVELS DURING SUMMER 2014 Due to summer camps, holiday weekends, and sports tournaments, our Saturday Travels program will be postponed until Fall Quarter. Please check out our Summer Sightseeing trips for other day trip options during the week.
Specialized Programs Adult Summer 2014
12
Camp Long Overnights - 2014 A beautiful, scenic get-away in the middle of West Seattle complete with a rustic lodge and cabins. Each cabin is equipped with bunk beds and electricity. Picnic table, stone fireplace, and running water available outside each cabin. Registration is limited to 50 campers. Due to staffing limitations we can take two wheelchair participants per session who do not have an assistant. We can take additional wheelchair campers if the individual has an aide. Camp Check-In: Begins Friday, 6 p.m. No Early Check-In’s (no dinner on Friday night) Access Riders – please schedule a drop-off time of 6:30 p.m. Camp Pick-Up:
Sunday, 1 p.m. Access Riders – please schedule a pick-up window of 12:30-1 p.m.
Cost:
$65 per camp session (DDD Respite / limited camperships available)
Payment:
You can pay with a credit card - or make check/money order payable to: City of Seattle Mail check with completed forms to:
Specialized Programs Section, Attn: Tori 4554 NE 41st Street, Seattle, WA 98105
Camp Location: 5200-35th Avenue SW – Seattle 98126 (corner of 35th SW & SW Dawson in West Seattle) Registration:
Call 206-684-4950 beginning at 8 a.m. on the registration date listed for each session. Names are taken on a first call – first serve basis until spaces are filled, after that time names will be put on a wait list.
NEW PARTICIPANT INFORMATION FORM There are NEW Participant Information forms this year which require a doctor’s signature if you take medications. Each participant must have a completed form turned in BEFORE camp or they will not be able to attend. If forms and fees are not turned in by the date listed, you will be placed on the wait list. For information on using DDD funds or request for a scholarship, please contact Tim at 206-615-0140.
Camp Dates & Registration Dates / Times: Camp Long #1
June 27 – June 29 Theme: Luau Weekend Aloha! Time for a mini tropical get-away right in our own Camp Long! Registration Begins: Wednesday, May 28 at 8 a.m. Forms & fees due in our office BY: Tuesday, June 17
Camp Long #2
July 18 – July 20 Theme: NW Sports Team Weekend Wear your fan gear for your favorite Seattle Teams: Mariners, Seahawks, Storm, Sounders, Thunderbird – how about Seattle Parks Sharks? Registration Begins: Tuesday, June 24 at 8 a.m. Forms & fees due in our office BY: Tuesday, July 8
Camp Long #3
August 8 – August 10 Theme: Talent Show Weekend Roll out the red carpet–it’s time for our spectacular Talent Show event! Registration Begins: Tuesday, July 15 at 8 a.m. Forms & fees due in our office BY: Tuesday, July 23
You do not need to send in the forms each time for Camp. Once we have the camper’s information form on file, it is good for each camp session registered for, unless there has been a change, i.e., medications, etc. Thank You. Specialized Programs Adult Summer 2014
13
SUGGESTED CLOTHING LIST FOR OVERNIGHT CAMP
Camp is a busy and fun time for all of us. Many of the activities get the camper dirty. Please send clothes that will not be damaged by a lot of activity. Please do not have campers bring valuable items/clothes because they might get lost or broken.
NOTE: We are not responsible for items lost or broken at camp.
Please Label Everything! Please keep in mind that there is limited space available.
Raincoat Jacket Hat Long Pants Short Pants Sweaters Sweatshirts Shirts Shoes Socks ( Bring extra )
Underpants ( Bring extra) Undershirts Pajamas (Bring 2 sets) Slippers / Bathrobe Toothbrush / Paste Toilet Kit Towel Hair Brush / Comb Soap, Box Wash Cloth
Sleeping Bag Blankets Pillow Duffle Bag Suitcase Diapers / Wipes (Bring extra) Glasses / Case Flashlight Any Special Equipment
.
Reminder: If the participant requires medication, you will need a doctor’s signature on the Participant Information form.
SCHOLARSHIP REQUESTS Funds for scholarships are limited, but every effort will be made to allocate some financial assistance towards program fees – there is no guarantee that you will receive aid. Please contact Tim Pretare at 206-615-0140 or email Tim.Pretare@seattle.gov to receive a Scholarship Application. You will be informed if your scholarship is approved and at what amount after we receive the application. .
Specialized Programs Adult Summer 2014
14
Seattle Parks and Recreation Specialized Programs SECTION 1: Participant Information and Authorization Please complete this form and submit to Specialized Programs;
this information is required for participation. We request that this information be reviewed and updated once per year. This information is considered confidential and is used only to help staff meet the needs of the Participant. Please fill out all sections completely (mark N/A if a section does not apply) and sign and initial where indicated. If there are any changes in the information on this form, please contact staff immediately to update, our office number is 206-684-4950. Please Print PARTICIPANT AND PARENT OR GUARDIAN INFORMATION
Primary Phone Number for Participant
Participant Name (First & Last)
Age
Date of Birth
Male
Address
City
Zip
School
Name of Parent, Guardian or other Signatory for Participant (First & Last)
Day Phone
Cell Phone
Student ID #
Grade
Evening Phone
Address (if different from above)
City
Zip
Relationship to Participant Parent Foster Parent Guardian Case Manager
Language(s) Spoken at Home
Group Home Staff Other
Name of Group Home or Agency Name (if applicable)
Administrator/Staff Name
Phone
Address
City
Zip
Participant would like to request or apply for DDD Respite Funds
Female
DDD Case Manager Name and Phone Number
Scholarship*
*A separate scholarship application is required
DDD Case Manager email: GENERAL AUTHORIZATION AND INFORMATION This Participant has permission to participate in field trips including, but not limited to, visits to a local library or park, neighborhood walk, or other field trip, by means of walking, public bus, Department van, yellow or charter bus. YES NO Initial Here This Participant has permission to participate in swimming and other water activities at Seattle Parks and Recreation facilities, including swimming pools, lifeguarded beaches, boating facilities, and wading pools. YES NO Initial Here Swimming Ability
Non Swimmer
Beginner
Intermediate
Advanced
Program staff have permission to apply sunscreen to this Participant during programs.
YES
NO
Initial Here
This Participant may be photographed (stills and video) for the City of Seattle, its Department of Parks and Recreation, the Associated Recreation Council, Advisory Council, or Community Center publications. YES NO Initial Here
TRANSPORTATION AND ACCESS INFORMATION Please help us identify the transportation methods the Participant will be using to get to and from programs by completing the section below. Please contact us if there are any special circumstances staff should know in regard to transportation. This Participant has permission to walk or take public transportation to and from programs. Does the Participant use Metro’s Access Service? Does this Participant require Hand to Hand service?
YES YES
NO NO
YES Door to Door service?
NO
Initial Here
YES
Access Van Company
Phone Number
ID Number
Alternate Van Company, School Bus, or other form of Transportation
Phone Number
ID Number
1
NO
Seattle Parks and Recreation Specialized Programs Participant’s Name
(First)
(Last)
EMERGENCY CONTACTS AND PICK-UP AUTHORIZATION AND INFORMATION The parent or guardian will be contacted first in case of emergency (after 911). Please list additional parents, family members, and others you would like us to contact if we cannot reach you in an emergency or for transportation reasons. 1) Contact Name (First & Last) Day Phone
Relationship to Participant Cell Phone
Address
Evening Phone
City
Zip
2) Contact Name (First & Last) Day Phone
Relationship to Participant Cell Phone
Address
Evening Phone
City
Zip
PARTICIPANT SIGN-IN AND SIGN-OUT PROCEDURES FOR MINORS ENROLLED IN YOUTH SUMMER CAMP The parent, guardian or other person listed above authorized by the parent to take the minor to and from the center or program site shall sign in the Participant on arrival and sign out the Participant at departure using a full, legal signature. LEGAL DOCUMENTATION INFORMATION Please complete the information below that pertains to the Participant, regarding documentation relating to a parenting plan or a current restraining order which has been issued by a legal authority and in effect in the State of Washington. Parenting Plan
YES NO
Expiration Date _________________________
If yes, provide a copy for Participant’s program file
Restraining Order
YES NO
Expiration Date _________________________
If yes, provide a copy for Participant’s program file
PARENTAL CONSENT, RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT EVENT(S): All programs and activities offered by or through Seattle Parks and Recreation and Associated Recreation Council including, but not limited to, recreation activities and classes, summer camp, afterschool programs, preschool, teen programs, special events, field trips, sports, and athletics. IN CONSIDERATION of the Participant being permitted to participate in any way in the EVENT(S), I agree: I know the nature of the EVENT(s) and the Participant’s experience and capabilities, and believe the Participant to be qualified to participate in the Event(s). The Participant and I will inspect the premises, facilities, and equipment to be used or with which the Participant may come in contact to ensure it is safe to our satisfaction. I have spoken with the Participant about the dangers of the activities and the fact that the Participant could-for a variety of known, unknown, foreseeable and unforeseeable reasons, including negligence of the City of Seattle, its employees and volunteers, officers and agents-be seriously injured. In extreme cases, such injuries could include permanent disability, paralysis or even death (“risks”). Even understanding these risks I consent to the participant’s participation in the Event(s) and assert that the Participant is willing to participate in the event. I accept and assume all risks, and assume all responsibility for the losses, costs and/or damages following an injury related to the Event(s), including disability, paralysis or death, even if caused in whole or in part by the negligence of the following releases: the City of Seattle, its employees and volunteers, officers and agents. My acceptance of these risks includes releasing and agreeing not to sue the releases. I also agree to indemnify and save and hold harmless the releases and each of them from any and all litigation expenses, attorney fees, loss, liability, damage, or cost they may incur due to a claim made against any of the releases identified above based on an injury to the Participant, whether the claim is based on the negligence of the releases or otherwise and whether the claim is made by me, is made on behalf of the Participant, or is otherwise made. X Signature of Parent, Guardian or other Signatory
Printed name of Signatory
2
Date
Seattle Parks and Recreation Specialized Programs SECTION 2: Medical History Participant’s Name
(First)
Height
(Last)
Weight
Does the Participant need 1 on 1 supervision?
Eye Color
YES
Will Participant be accompanied by an attendant?
NO YES
Attendant’s Name
Hair Color Is direct line of sight required?
NO
YES NO
If yes, please fill in the information below
Phone Number
Physician Name
Physician Phone
Physician Address
City
Medical Insurance Company
Policy Number
Zip
Preferred Hospital for Treatment This Participant experiences the following: Please check ‘None’ or all that applies. Providing this information will help us to ensure the Participant has a positive experience. Efforts will be made to provide reasonable accommodation in accordance with the Americans with Disabilities Act. Unless you have religious objections, we cannot allow the Participant to participate without this information and the included authorizations. If you have religious objections, please submit a written statement of those objections.
None
ADD
ADHD
Allergies
Asthma
Asperger’s Syndrome
Autism
Behavior Disorder
Developmental Disability
Diabetes
Hearing Impairment
Learning Disability
Mental Disability
Physical Disability
History of Seizures
Visual Impairment
MOBILITY-WALKS
Independent With Support TRANSFERS
Independent
Currently Taking Medications at Home School Program None
Other
Balance Issues Crutches Cane or Walker
WHEELCHAIR power cord with chair
Manual (select one below) Independent Dependent
Stand-by Supervision To Toilet
In and Out of Bed To Floor
Assist – 1 person Assist – 2 people
CPAP Braces (type) __________ Night Braces
Prosthesis
Shunt
Dentures
Helmet
Glasses
Hearing Aid
Power Please keep
Comments ADAPTIVE DEVICES None
Splint Other -
Please label devices with Participants name in instructions for use whenever possible. SEIZURES Does the Participant have a history of seizures?
YES
NO
Has the participant been hospitalized or received rescue medications?
YES
NO
Do seizures typically last more than 3 minutes?
YES
NO
Last hospitalization date ____________________________ What rescue medication was used _______________________________________ Describe what recovery is like ___________________________________________________________________________________________ ___________________________________________________________________________________________________________________ *If the Participant has a seizure protocol, please attach it with any additional information on a separate sheet.
3
Seattle Parks and Recreation Specialized Programs
Participant’s Name
(First)
(Last)
ALLERGIES (please list any known allergies) Food Allergies Yes Food allergic to – Mild Severe
No
Asthma Mild Severe Inhaler YES NO
Insects (type) _____________________ Mild Severe Epi-Pen Yes No
Food Allergic to – Mild Severe
Other -
Pollens Mild Severe What needs to be done if an allergic reaction occurs? EATING
FOOD PREPARATION
No Assist
None
Partial Assist
Chopped
Total Assist
Blended
Tube Fed
Other -
Difficulty Swallowing Adaptive Utensils (type) Problem Foods (please list)
DIETARY NEEDS Please describe any special diet
Please list any particularly disliked foods
Will the Participant be bringing personal food to programs? YES
NO
Are there any foods the Participant must avoid or be controlled for? YES
If yes, please list
NO
If yes, please list
TOILETING No Assist
BLADDER CONTROL Normal
BOWEL CONTROL Normal
AIDS USED None
Partial Assist
Partial
Partial
Bedpan
Total Assist
Incontinent
Incontinent
Diapers
Other
Reminders
Reminders
Night-Time Depends
Laxative
Other -
Catheter YES
NO (list type) -
Comments For females, what is the approximate date of menstrual cycle?
OVER THE COUNTER MEDICATION Can Over-the-Counter medications be administered to the Participant while in programs? I would prefer a telephone call from staff before Over-the-Counter medications are administered Medication
Check yes if OK to give
Dosage
Medication
YES YES
NO NO
Check yes if OK to give
Tylenol
YES
NO
Pepto Bismol
YES
NO
Ibuprofen
YES
NO
Tums
YES
NO
Benadryl
YES
NO
Other -
YES
NO
Sudafed
YES
NO
Other -
YES
NO
4
Dosage
Seattle Parks and Recreation Specialized Programs Participant’s Name
(First)
(Last)
MEDICAL HISTORY Does or has the Participant had any of the following (record date where applicable) Date
Date
Date
Arthritis
Bleeding Disorder
Chicken Pox
Ear Infections
Hypertension
Measles
Heart Defect
Mononucleosis
Rubella
Diabetes
Decubitus Ulcer
Mumps
IMMUNIZATION HISTORY Write the date of basic immunizations, and most recent booster, or write “unknown” and initial Date Date DPT
Rubella
Tuberculosis (T.B.)
Polio
Small Pox
Mumps
Measles
Tetanus
Other -
Verbal
Communication Board
Non-Verbal
Verbal (Hard to Understand)
Communication Book
Gestures
Verbal with Adaptive Equipment
Electronic Communication
Sign Language
Date
COMMUNICATION (please check all that apply)
Comments
BEHAVIORS Does the Participant have a current Behavior Plan? YES copy of the plan on a separate sheet
NO
If yes, briefly describe the nature of the plan and include a
How can we encourage positive behaviors?
How can we prevent and discourage problem behaviors?
What types of noises, activities, or situations bother the Participant?
What are his or her reactions?
Does the Participant have any other sensitivity?
Please describe the Participants sleeping habits (wets bed, night lights, etc.)
Does the Participant have a history of wandering?
YES
NO
If yes, what are the triggers?
Please tell us anything else pertaining to the needs of the Participant *if there is any additional information to include, please attach additional pages of information.
5
Seattle Parks and Recreation Specialized Programs SECTION 3: Medical Treatment Authorization Message to Parent, Guardian or other Signatory: Medical Treatment Authorization must be signed by a physician and is required for any medication taken or administered while in a Seattle Parks and Recreation, Associated Recreation Council or Advisory Council program. State law prevents our personnel from administering medication unless we have a signed note from a physician stating dosage and procedure. If medication is required to be administered during programs, please bring this form and the medication in its prescription bottle and give it to a staff member. All medications must be dispersed by a staff member. Please do not leave medications in the possession of the Participant or with his or her personal belongings. Write the time the medicine needs to be given. Let us know if the medication needs to be stored in a special way, i.e., in the refrigerator, or away from sunlight. Thank You! Participant’s Name
(First)
(Last)
Does the Participant have any known drug allergies: YES
CURRENT MEDICATIONS Medication Name
NO
If yes, please list here
Method of Administration Dosage
Orally, with water, applesauce, Injection or other
Time(s) Taken ( check all that apply ) Wake Up
Breakfast
Lunch
Afternoon
Dinner
Bed-Time
1. 2. 3. 4. 5. 6. Do any medications require special handling?
YES
NO
If yes, which ones _________________________________________
Comments OTHER SPECIAL TREATMENTS Will the Participant need any special treatments ordered by a Doctor while in program?
YES
NO If yes, please explain
MEDICAL AUTHORIZATION I authorize the administration of all medical, dental, and surgical examinations, operations, treatment, and all related care, including emergency or ambulance transportation and the administration of drugs, tests, anesthesia and blood transfusions to the above-named Participant when a physician or dentist at the treating medical facility deems those procedures necessary for emergency treatment. I consent to the release of medical report(s) to any doctor or agency and consent to the admission of the above-named Participant to the hospital. I understand that the City of Seattle, its Department of Parks and Recreation, Associated Recreation Council, Advisory Councils, the Community Center, and their officers, employees, and volunteers assume no financial obligation or liability in case of the Participant’s accident or illness. I assume full financial responsibility for emergency treatment for the participant. I authorize the program staff to give the above listed medication(s) and/or treatment(s) to the Participant
No Medication If this Participant DOES NOT require any medication, then Physician signature is not required.
Participant Full Name: (Please Print)
First Name
Middle Initial
Last Name
Date of Birth
X Signature of Parent, Guardian or other Signatory
Printed Name of Signatory
Date
Physician Name (please print)
Date
X Physician Signature
6
2014 ADULT DDD RESPITE FORM Scholarship:
Funds for scholarships are limited, but every effort will be made to allocate some financial assistance toward program fees – there is no guarantee that you will receive aid. Please contact Tim Pretare at 206-615-0140 or email Tim.Pretare@seattle.gov to receive a Scholarship Application. You will be informed if your scholarship is approved and at what amount after we receive the application.
DDD Funding:
If you have DDD funds, please fill out the form below, after you have contacted your case manager to be sure there are funds in your account. We will apply approved funds to the summer activities / camp sessions you request.
This is not a Registration Form. You need to call to register on the date listed for summer activities and for Camp Long overnights. See Registration Information on the program pages in this brochure.
NAME:
(First)
(Last)
AGE: ________________
BIRTHDATE:
I would like to request DDD funding for the following programs / activities:
Cooking
Camp Long 1
June 27 – 29
TNT
Camp Long 2
July 18 – 20
Camp Long 3
Aug. 8 – 10
DDD respite applicants must provide the following information before being accepted to attending camp. Please make arrangements with your case manager prior to sending in this request. PLEASE NOTE:
Case Manager’s Name: Case Managers Area Code & Phone Number: (
)
Case Manager’s Email: Parent / Guardian Name: (Please Print) Home Phone & Area Code: (
)
Work Phone & Area code: (
)
Cell Phone: (
Parent/Guardian Email:
Specialized Programs Adult Summer 2014
21
)
Presorted Standard U.S. POSTAGE
PAID SEATTLE, WA. PERMIT NO. 152
Specialized Programs 4554 NE 41st Street Seattle, Washington 98105
CHANGE SERVICE REQUESTED
Note:
Specialized Programs staff are not at Big Day of Play to supervise. Please send a chaperone if supervision is needed.