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Spofford change action & mastery programs

Spofford SCAMPS 2013 Application
Child’s Name: __________________________________ DOB: ___/___/___ Gender: _____ School: ________________________________________ 2012-2013 Grade Level: K 1 2 3 4 5 6 7 School District: _________________________________ One Session: June 3rd- July 26th

Home Address: ____________________________________ City, State, & Zip: ______________________
Work Phone: ______________

Cell Phone: ______________
Home Phone: ______________

Father/Guardian Name: _________________________ Employer: ______________________________
Mother/Guardian Name: _________________________ Employer: ______________________________
Please list all individuals other than the parents/guardians who are authorized to pick up the child from
camp. If individuals are not listed on your child’s application, staff will not release your child to them
:
Name: ___________________________________
Relationship to child: _______________________ Name: ___________________________________ Relationship to child: _______________________

Emergency Contact Name
: _________________________________________________________________
Work Phone: ______________ Cell Phone: ______________ Home Phone: ______________

Child’s Strengths & Interests:
_______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Current Diagnosis
(please check all that apply):
Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425 Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439

___________________________________________________________________________________________
___________________________________________________________________________________________

___________________________________________________________________________________________


My child has no current diagnosis

Behavioral Concerns:

1.) Please describe any concerning behaviors your child exhibits at home, school, or in the community? _______
__________________________________________________________________________________________
__________________________________________________________________________________________
2.) What does your child do when he or she is upset?
___________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
3.) What types of situations or triggers may cause problems for your child? ______________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
4.) What tends to work in calming your child down when he or she is upset?
________________________________

___________________________________________________________________________________________
___________________________________________________________________________________________

5.) What types of rewards and/or consequences do you use at home that are successful with your child?
__________________________________________________________________________________________

___________________________________________________________________________________________
___________________________________________________________________________________________

Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425 Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439

6.) Has your child exhibited any physical aggression at home, school or within the community and if so please
describe in detail? ____________________________________________________________________________

____________________________________________________________________________________________
____________________________________________________________________________________________
Educational Information:

My child participates in regular education classes My child is currently in a self contained classroom at his/her school My child currently has an IEP or 504 plan (please attach copy to application) My child has been suspended or expelled from school in the past 6 months (please describe below) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Please indicate how you heard about the SCAMPS summer program: ____________________________________
___________________________________________________________________________________
_________________________________________________________________________________________
Health Concerns/Other Physical Ailments
(Physical impairments, conditions, or allergies that may interfere with
daily activities):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425 Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439
Consent for SCAMPS staff to administer the following over the counter medications:
Comments
Acetaminophen
_________________________________
Ibuprofen
_________________________________
Robitussin DM
_________________________________
Cepacol Lozenges/spray
_________________________________
Little noses saline drops
_________________________________
Imodium AD
_________________________________
Stool Softener
_________________________________
Milk of Magnesia
_________________________________
Calamine Lotion
_________________________________
Caladryl Lotion
_________________________________
Hydrocortisone cream
_________________________________
Benadryl
_________________________________
Triple antibiotic ointment YES NO
_________________________________
Current Medications: (Please list all prescribed and over-the-counter medications, including inhalers, how long
your child been on these medications and any side effects of the medications?)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425 Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439
Financial Information
1. What is the total monthly income for your household? _____________ 2. What amount do you feel you can afford to pay toward camp fee $____________ (Please note that payment must be received by Monday of each week in order for your child to attend
camp.)

3. Payment plans are available. Would you like to set up a payment plan? YES NO If yes, please indicate the amount $________ per week that you are able to pay. I give my permission for SCAMPS staff to contact my child’s current teacher and/or mental health provider. Please indicate the name and contact information for the above stated individuals. I, the undersigned, attest to the accuracy of the information I have provided. I understand that the information will be kept confidential, in accordance with HIPPA Laws and shall only be reviewed by those individuals directly involved in the care of my child. ________________________ Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425 Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439
AUTHORIZATION AND RELEASE FOR THE USE AND/OR DISCLOSURE OF PROTECTED HEALTH
INFORMATION FOR PROGRAM PURPOSES
I, the undersigned, do hereby authorize that photographs may be taken by Spofford of my child for publication in future web and print advertisements and literature for Spofford’s SCAMPS Summer Day Camp. The purpose of any publication is to provide awareness of and publicize Spofford’s activities, programs, and services. I understand that my child will not be identified by his/her full name. I understand that I am not required to sign this Authorization and, if signed, I may revoke this at any time except to the extent that actions have been taken in reliance on this Authorization. To revoke the Authorization, I may contact the Privacy Officer, PO Box 480227, Kansas City, MO 64148-0227 or by telephone at 816-508-3499. This Authorization expires ________________________ (if I do not provide a date in the blank, this Authorization expires 90 days from the date that I sign this Authorization). I understand that expiration of this Authorization will not cause any publication made as a result of this Authorization to be withdrawn from public circulation at the time of expiration or any time thereafter. I understand that Spofford cannot condition treatment or payment on obtaining this authorization from me unless otherwise permitted by law. I understand that I have the right to inspect or copy the protected health information to be used or disclosed. I understand that Spofford may receive donations from third parties as a result of this Authorization. I understand that if the person or entity that receives the information is not a health care provider that the information may be re-disclosed and is no longer protected by the privacy regulations. I agree that neither my child nor I will receive any financial remuneration for the use of his/her image as described herein. I hereby release and discharge Spofford and its affiliated agencies, their directors, officers, successors, and assignees and their respective employees, representatives, and agents from and against any and all liability, including reasonable attorneys’ fees, arising out of the exercise of the rights granted by this authorization. It is further understood and agreed that this waiver and release is to be binding upon myself, the minor child, other family members, and my heirs and assigns. I acknowledge that have read and fully understand this Authorization and Release and am voluntarily signing this Agreement ______________________________________________ Printed Name of Legal Custodian (if child is a minor) _______________________________________________ Signature of Legal Custodian (if child is a minor) ______________________________________________ Printed Name of Legal Custodian (if child is a minor) _______________________________________________ Signature of Legal Custodian (if child is a minor) ______________________________________________ Please return completed form to:
SCAMPS, Spofford, 9700 Grandview Road, Kansas City, Missouri 64134, Fax 816-508-3425 Questions or comments please contact: Steve Walker 816-508-3494 or Becky Hirner 816-508-3439

Source: http://64-151-48-15.static.everestkc.net/enewsletters/SCAMPSAPP2013.pdf

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