The Participation House (Durham Region)

Life Readiness Camp Application

Please Provide the Following Information:

or Download Print and Fax Application

Download Here

Personal Information

First Name

Last Name

Address

City

Postal Code

Home Phone Number

Contact Information

Parent/Guardian Name

Home Phone Number

Alt. Phone Number

Address

City

Postal Code

Alternate Emergency Contacts

Primary Contact

Home Phone Number

Alt. Phone Number

Address

City

Postal Code

Relationship

Secondary Contact

Home Phone Number

Alt. Phone Number

Address

City

Postal Code

Relationship

Health Information

Primary Disability

Brief Description

Other Conditions / Health Conditions

Allergies (Please List All Food and/or Medication

Do you use an Epi-Pen?

Current Medications Dosages and Administration Times

Communication

Do you wear Hearing Aids?

Do you have Speech Difficulties?

IF you answered yes to either of the above questions, please indicate how you communicate

Specify (Other)

Social Development

IT IS IMPERATIVE THAT THIS SECTION IS FILLED OUT ACCURATELY SO THAT WE CAN PROVIDE THE SUPP0RT REQUIRED TO MAKE THIS A SUCCESSFUL EXPERIENCE FOR ALL PARTICIPANTS

Choose one of the options describe your social interactions

Choose one of the following to describe your decision making skills?

Choose one of the following statements to describe how you react with increased anxiety…

When I am anxious or upset I am able to remove myself from a situation and use coping mechanisms to relax.

When I am anxious or upset I will sometimes hurt myself.

When I am anxious or upset I will direct my anger at another person through verbal or physical aggression.

If you answered with statement 2 or 3 from the above question, please answer the following.

I experience behaviors of concern

Care Provisions

Please answer the following if you take prescribed medications.

I do not need any assistance with taking my medication.

I need prompting that it is time to take my medication.

I need complete assistance in taking my medication.

Do you have any special dietary needs or restrictions?

If yes what are your needs

Other

Do you require turning at night?

If Yes Please Specify

Please indicate the level of assistance required for each of the following activities

Eating

Brushing Teeth

Grooming / Shaving

Washing Hand/Face

Dressing

Showering / Bathing

Toileting

Do you require assistance with transferring?

If Yes Please Specify

How do you complete your personal care?

Are there any other specialized equipment/services you require that have not been mentioned?

If Yes Please Specify

Session Dates

Please note that the program will run from Monday-Saturday. The first day will be held at The Participation House Project (Durham

Region) from 9-3:30 pm. Tuesday -Friday will be overnight stays at Durham College Residence. Saturday there will be a celebration

with participants, friends and family ending at 1:00pm.

Which week do you prefer.

Transportation

Participants or their families must arrange transportation for the individual to get to and from the location for the first day of the program. The remaining four days participants will be utilizing public transit for transportation purposes.

Program Fees

The program fee of $100.00 will cover the cost of accommodation, transportation, meals and snacks for the first day of the program.

Payment is required through cash or money order. Cancellations must be made by June 22, 2007 to receive a full refund. Payment of the program fee is required upon acceptance to the program

The $75.00 spending allowance that each participant is expected to bring will be used during the overnight portion of the program as a

learning tool to budget for recreational activities, and other incidentals.

If you have any questions Please Contact:

Sue Pereira

The Participation House Project (Durham Region)

Phone: 905-579-5267 x26

Fax: 905-579-5281

spereira@phdurham.com


ph: 905.579.5267	The Participation House Project (Durham Region)	contact@phdurham.com