Camp ECHO – Camper Application | Wood County Society

Camp ECHO 2024 Participant Application

INFORMED CONSENT AGREEMENT

The following Consent Agreement outlines several types of services or activities that may be made available to you, your child, or your family member by Wood County Society (WCS or “agency”). Please read each statement carefully and be certain that you understand the statements before consenting to participate in services provided by our agency. The bottom of the page includes designated space to include an explanation for which you do not provide consent. Consent is not time limited. If you wish to withdraw your consent after it has been given, please contact Brandon Gress, Executive Director at the address below. Brandon Gress, M.A. Executive Director Wood County Society P.O. Box 1325 Parkersburg, WV 26102 (304) 428-4280 Ext. 1

CONSENT FOR SERVICES

I understand the purpose of WCS is to broaden opportunities for all individuals with disabilities throughout the Mid-Ohio Valley Region. These services may include but are not limited to receiving library materials, training, family coaching, direct services, and taking part in one of the 19 programs offered.

I understand that there is no guaranteed time by which I, my child, or family member will be selected for services.
I understand I must be willing to make a commitment to work with others who support my child or family member.

I understand I am free to withdraw as a registered consumer at any time without penalty to me, my child, or my family member.
I consent to allowing staff of WCS to observe me, my child or my family member should such an observation be deemed necessary by both parties.
I understand that WCS is not responsible for any fees or charges that result from additional assessments, i.e., medical exams, even if these evaluations are recommended by WCS.
Participation in any service may involve some risk, including the loss of confidentiality. I understand that WCS will take all reasonable precautions to ensure confidentiality as prescribed by law.
The direct care service programs are based on a body of literature which supports the notion that caregivers are vital components for the positive prognosis for their children/family member.
Wood County Society staff are mandated to report to Child or Adult Protective Services should they obtain knowledge of or suspect abuse or neglect.
You are free to question the use of any procedure, and you may request that a specific procedure(s) not be used. Any procedure in question will be terminated upon your request even after the procedure has started. Your request for termination of a specific procedure(s) will not affect you or your child/family member’s continued participation in the program.
You are free to withdraw your consent at any time without penalty to you or your child/family member. You will still be eligible for other services and programs offered by WCS.
As with any service program, there is a chance that the program will not produce any significant changes for your child or family member.
In the event of injury or illness as a result of participating in this program, WCS shall not be held responsible. The cost of medical care will be your responsibility.
The time commitment for attending meetings, trainings, and implementing procedures at home may be viewed as disruptive to normal family schedules. All efforts to accommodate family schedules will be made.
This consent allows WCS to alert school personnel (special education director, principals, teachers and specialists) that we will be providing support to your child or family member and will be inviting them to participate.
Any questions or concerns may be directed to:

Brandon Gress, M.A. Executive Director Wood County Society P.O. Box 1325 Parkersburg, WV 26102 (304) 428-4280 Ext. 1

CONSENT FOR MEDIA

I consent to allow WCS to create digital audio or video recordings or take photographs of me and/or my child or family member with my permission. I understand recordings and/or photographs may be used for training others to work with and understand persons with disabilities, to increase public awareness, be used in scholarly or training activities as well as the Wood County Society Telethon on-air, social media pages, publication, brochures, newspapers, commercials, and bulletin boards. I understand my name and the names of those in my family will be kept confidential. I understand that I have no authority to amend the content of visual or auditory media. Further, I understand that I have no legal right to any financial remuneration from this experience. I understand I will be alerted prior to the use of media in which I, my child, or my family member is involved. I also understand I may revoke this Consent for Media permission at any time during my relationship with WCS.

AGREEMENT & EXCEPTIONS

Please select I Agree or I Disagree beside the category for which you provide informed consent. If you wish to withhold consent, or modify your consent in some manner, please explain your intent in the space provided. Consent is not time limited. If you wish to withdraw your consent after it has been given, please contact Brandon Gress, Executive Director. Please note: by providing your consent specific to the program, you are agreeing to participate in these programs, and allow WCS to exchange information with schools or other institutions that serve the client. Consent to Services I AgreeI Disagree Consent to Media I AgreeI Disagree Individual's Name: Parent / Guardian's Name (optional): Signature:

Date:

First Name:

Last Name:

Shirt Size:

Nickname:

Mailing Address:

City:

Email Address:

Date of Birth:

Sex: FemaleMale

Guardian / Caregiver:

Phone (Home):

Phone (Work):

Phone (Mobile):

Email Address:

What does the participant enjoy doing most? (This can be at the end; It helps mentors build positive relationships with the participant)

Will participant be bringing their own staff? YesNo

If yes, Staff Name:

Is participant with an agency? If so, please complete the following fields: YesNo

Agency:

Phone:

Street Address:

City:

State:

Zip Code:

Direct contact for Agency:

Direct contact Phone (Work):

Direct contact Phone (Mobile):

Demographic Information: Information is for participant only and is used for grant-writing purposes only. Please select one.

Wood County Society

Medical Consent Form

Participant Information

First Name:

Last Name:

Date of Birth:

Age:

Height:

Weight:

Sex: FemaleMale

Mailing Address:

City

State:

Zip Code:

Primary Disability:

Other medical diagnoses, if any:

Has participant received a COVID-19 vaccination? NoYes

If YES, please provide a copy of the vaccination card via the Attachments section below. If NO, please explain the reason (i.e. health condition or not advised by medical professionals)

Does the participant have health concerns that would inhibit wearing a mask? NoYes

Is the patient allergic to latex NoYes

Is the participant allergic to cleaners such as Lysol, Bleach, and Disinfectant Sprays? NoYes

Parent/Caregiver Contact Information

Parent/Caregiver:

Mailing Address:

City:

State:

Zip Code:

Best Contact Number:

Email:

Emergency Contacts

Please list (in order) the perosn we should call in the event of a medical, behavioral, or other emergency.

Name:

Relationship to participant:

Phone (Primary):

Phone (Mobile):

Name:

Relationship to participant:

Phone (Primary):

Phone (Mobile):

Physician Name:

Physician Phone:

Insurance

A front and back copy of all insurance cards must be attached below.

Primary Health Insurance:

Policy Number:

Policy Subscriber Name (if different than participant):

Secondary Health Insurance:

Policy Number:

Policy Subscriber Name (if different than participant):

Medical Information

All medications will be turned over to the medical staff at the time that participants are checked in. All medications (including non-prescription) will be dispensed by the designated member of that staff. All medications are to be in original pharmacy-labeled medication containers. If the participant currentlyt has a MAR sheet, it must be attached to this form below. If a participant does not require the use of a MAR, all medications must be listed below.

MAR Sheet attached: NoYes

Medication:

Dosage/Frequency:

Medication:

Dosage/Frequency:

Medication:

Dosage/Frequency:

Medication:

Dosage/Frequency:

Medication:

Dosage/Frequency:

Best person to call regarding medication questions:

Does this participant have food, drug, or bee allergies? No food, drug, or bee allergiesFoodDrugBee

Please list any food allergies:

Please list any drug allergies or interactions:

Does this participant require support procedures that must be administered by a qualified staff person? NoYes

Please describe any required support needs (i.e. feeding tube, catheter):

Does this participant have seizures? NoYes

Date of last seizure:

If the participant has seizures, please note the type, frequency, and length:

The following non-prescription OTC medications may be available for use on an "as needed" basis to manage illness and injury. Please mark all that camp staff are allowed to administer to the participant, even if already listed on MAR.

Aspirin: NoYes

Ibuprofen (Advil, Motrin): NoYes

Benadryl: NoYes

Acetaminophen (Tylenol): NoYes

Pepto-Bismol: NoYes

Epi-Pen: NoYes

Does the participant have any dietary restrictions? NoYes

If yes, please explain.

Does the participant have special food/liquid needs as described (i.e. puree, feeding tube, etc)? NoYes

If yes, please explain.

Attachments

Insurance Card (Front):

Insurance Card (Back):

COVID-19 Vaccination Card:

MAR Sheet:

Self/Parent/Guardian Signature:

Date:

Mobility & Positioning

If participant uses a wheelchair, how do they transfer? AloneWith Assistance

If participant uses a brace, what does it support? BackNeckLegFeet

Can participant bear weight? NoYes

Comments

Social, Environmental, Verbal, Non-verbal Triggers

Please list specific instances of triggers (words, phrases, animals, bugs, people)

Please describe what occurs with the behavior.

What strategies or method(s) are used for calming or de-escalation?

Toileting

Does applicant use the a toilet appropriately? Will state needVerbal promptPhysical assistance

Does applicant manage their own personal care (wiping)? IndependentlyVerbal PromptPhysical Assistance

Does applicant use a catheter? No CatheterIndependentlyPhysical Assistance

Does applicant wear absorbent briefs? No Absorbent BriefsDayNightBoth Day and Night

Comments:

Hygiene

Does applicant take a shower? IndependentlyVerbal PromptPhysical Assistance

Does applicant dry themselves? IndependentlyVerbal PromptPhysical Assistance

Does applicant shampoo hair? IndependentlyVerbal PromptPhysical Assistance

Does applicant brush their teeth? IndependentlyVerbal PromptPhysical Assistance

Comments (if refusal, how to persuade):

Communication

Does participant communicate verbally? NoYes

Does participant communicate using Sign Language? NoYes

Does participant require a communication device? NoYes

If so, does the device need to be charged? NoYes

Device / App Name:

Comments:

Other Assistive Devices

Additional devices or items (please describe):

Nighttime Routine

Does participant sleep through the night? NoYes

If participant has positioning requirements, please explain:

If participant has special sleep habits, please explain:

If participant has a history of sleepwalking, please explain:

If participant has history of wetting or soiling bed, please explain:

Comments:

Eating and Drinking

How does applicant eat? IndependentlyVerbal PromptPhysical Assistance

How does applicant drink? IndependentlyVerbal PromptPhysical Assistance

If participant needs special positioning, please describe:

If participant uses adaptive equipment, please describe:

Comments:

Dressing / Undressing

How does applicant get dressed? IndependentlyVerbal PromptPhysical Assistance

How does get undressed? IndependentlyVerbal PromptPhysical Assistance

Comments:

Additional Information

If applicant uses assistive equipment, how do they care for it? IndependentlyVerbal PromptPhysical Assistance

Does participant have seizures? NoYes

Has the participant ever been away from home overnight? NoYes

Does the participant do well in groups? NoYes

Other Helpful Information

Pleaes include any other information you feel would be helpful to camp staff or nurses: