Chemical Dependency

2016 Vacation Registration

Guest Information Details
Name
(as it appears on birth certificate or passport) / First / Middle / Last
Address / Street: / Apt #
City: / Province/State: / Postal/Zip:
Phone: ( ) / Email:
Date of Birth: / /
MM/DD/YYYY / Gender
M F / Preferred Name:
Should information about the vacation be sent to this address? Yes No
If ‘No’ is selected, we will automatically keep the primary contact information on file as a contact.
Primary Contact
Name of Organization/ / Program Name: / Relationship to guest:
Contact Person / Name
Address / Street: / Apt #
City: / Province/State: / Postal Code/Zip:
Phone: ( ) / Email:
Are you at home when the guest is on their vacation? Yes No
If no, please indicate an alternate number or contact:
Secondary Emergency Contact
Contact Person / Name
Address / Street: / Apt #
City: / Province/State: / Postal Code/Zip:
Phone: ( ) / Email:
Are you at home when the guest is on their vacation? Yes No
If no, please indicate an alternate number:
Diagnosis and Communication Please check all that apply

Diagnosis

ax 519.650.8984

□ None

□ Chemical dependency

□ Cerebral palsy

□ Autism

□ Deafness

□ Blindness

□ Developmental disability

□ Brain or neurological damage, chronic brain syndrome

□ Epilepsy or seizures

ax 519.650.8984

□ Situational mental health problem (formal diagnosis), depression, anxiety, fearfulness, mood disturbance

ax 519.650.8984

□ Syndrome (please specify) ______

□ Other (please specify) ______

ax 519.650.8984

Based on the above, what is the primary diagnosis of the applicant? (list one)
Please describe any physical limitations
Does the guest use a wheelchair? □ Yes □ No □ Electric □ Only if needed/requested
If yes, electric and by need/request, we ask that you provide the wheelchair for their vacation.
Does the guest require assistance for transfers? □ 1 person □ 2 person □ Mechanical □ Independent
Is the guest able to use the top bunk? □ Yes □ No
Is the guest’s speech understandable? □ Yes □ No □ Somewhat
Guest uses: □ Sign Language □ Bliss □ Pictures □ Other ______
*If guest uses any form of communication tools, please attach a description and be sure to send their tools on their vacation.
Social/Behaviour Considerations Please check all that apply
Would the guest like to room with a friend? Name:
Has the guest been away from home before? □ Yes, ______days □ No
How long can the guest be left alone? ______minutes ______hours □ Cannot be left alone
Does the guest enjoy swimming? □ Yes, Shallow □ Yes, Deep □ No □ Requires life jacket
What recreational activities does the guest currently enjoy?
How do they participate? □ Willingly □ With encouragement □ Seldom □ Never
Please list any significant fears:
How does the guest: / Respect the privacy of others? □ Good □ Fair □ Poor
Initiate interaction with others? □ Good □ Fair □ Poor
Interact in a group? □ Good □ Fair □ Not at all
Tolerate frustration? □ Tolerates □ Withdraws □ Cannot tolerate, loses control
Problem solve? □ Independent □ Some assistance □ Full Support Needed
Adapt to change? □ Adapts □ Withdraws □ Cannot adapt, loses control
Describe the guest’s orientation: □ Aware of situation □ Aware, may confuse factors □ Not aware, generally
Does the guest engage in behaviours that require intervention? □ Never □ Rarely □ Frequently
Please attach any directions for interventions.
Please describe any behavioural changes in the last year:
Does the guest require any behavioural PRN medication? □ Yes □ No
What behaviour change does the medication facilitate?
Please note: If the guest requires a behaviour modification program, please attach it to the application.
Sexuality
Please comment on any concerns regarding sexual issues: ______
______
Medical Information
A doctor’s medical examination is not required. Please complete the following to confirm general condition of the guests health.
Is the guest subject to seizures? □ Yes □ No If Yes, please list frequency and type:
Describe a typical seizure:
At what point during a seizure should 911 be contacted?
Is a record of seizures required? □ Yes □ No
If yes, please provide documentation to be kept.
If the guest has Down Syndrome, have they been tested for Atlanto-Axial Dislocation? □ Yes □ No
Result:
Please list any allergies and the required intervention:
Is the guest a Hepatitis B Carrier? □ Yes □ No
Guest’s height and weight: LBS Feet Inches
Please list any other conditions or communicable diseases which present a health hazard:
Physical Health

Does the guest experience:

ax 519.650.8984

□ Shortness of breath

□ Edema (tissue swelling)

□ Persistent cough

□ Headaches

□ Nightmares

□ Diarrhea

□ Joint inflammation

□ Sleep apnea

□ Constipation

□ Insomnia

□ Over fatigue

□ Anuria (kidney dysfunction)

ax 519.650.8984

How are these problems normally treated?
Do any of these problems need to be monitored by our health care staff?
Please indicate any abnormalities that exist and give detail regarding:
□ Eyes □ Nose □ Ears □ Mouth □ Skin □ Spine □ Neurological □ Chest/heart
Details:______
______
Does the guest exaggerate physical or other problems to seek attention? □ Yes □ No
Please describe
Menstruation: □ Normal □ Pain/Discomfort
If cycle is due while on vacation, please provide all supplies and inform support staff.
Other Health Concerns
Recent major illness & When: Saw doctor? □ Yes □ No
Has the guest been hospitalized in the last year? □ Yes □ No If yes, indicate reason:
Describe any significant medical or physical changes in the last year
Are all vaccinations up to date? □ Yes □ No If no, please ensure they are all up to date before vacation begins.
Does the guest have any conditions requiring medical treatment while on vacation? □ Yes □ No
Please explain:

Does the guest usually sleep throughout the night? □ Yes □ No

Does the guest require over night support? (Incontinent supply change, etc) □ Yes □ No

Describe typical sleep patterns: ______

Diet
Allergies and Diet Restrictions
□ Lactose Intolerant □ Gluten free diet □ Nut allergy □ Other allergy ______
Assistance needed at meal times:
□ Fully independent □ Needs food cut □ Needs puree diet □ Uses drinking straw □ Uses adapted utensils (please send)
□ GI feeding □ Needs to be fed by staff □ Other ______
Food and Eating Disorders
□ Diabetes □ Anorexia □ Bulimia Nervosa □ Prader Willi Syndrome □ Other
Please indicate any restrictions, suggested meals and desserts. If a specific diet must be followed, please attach a copy to the application.
Hygiene Assistance
Please indicate by entering the appropriate letter, the level of care required for each activity
I- Independent R- Reminders Only V- Verbal Prompting H- Hand over hand assistance F- Full Assistance
Dressing / Showering / Washing hair / Brushing hair / Deodorant
Shaving / Brushing Teeth / Using toilet / Menstrual hygiene / Incontinence supplies

ax 519.650.8984

ax 519.650.8984

Level of Support Recommended:
□ Independent □ 3 guests: 1 support staff □ 1 guest: 1 support staff (additional cost)
Indicate reasons if not already described in application
______
______
______
______
Vacations
Are you interested in a carpool at an additional cost from Kitchener, if offered? / □ Yes □ No
Excursion 1 / Fee:
Excursion 2 / Fee:
Excursion 3 / Fee:
Total:

*International Vacation applications must be submitted with a copy of a valid passport.

*Travel/Medical Insurance is included in all international vacation fees.

Camps
Camp 1 / Date: / Fee:
Camp 2 / Date: / Fee:
Camp 3 / Date: / Fee:
Provide another option if your choice above is not available / Total:

Comments

Spending, Tuck Shop & T-Shirt Request
Spending money or tuck shop deposit may be added to this bill or brought in cash to the vacation.
All unused funds are refunded upon pick up. / Deposit $
T-Shirt - $15 each S M L XL 2XL 3XL / Total:
Total & Deposit
Vacation + Camp + Spending & T-Shirt = / $
Refundable $200 deposit for each Camp + $500 deposit for each Vacation = / $
Payment Method
□ Cheque enclosed payable to Christian Horizons Vacation Services
□ Visa □ Master Card
Card #
Expiry Date: /
Cardholder’s Name:
Cardholder’s Signature:
Phone Number: ( )

All vacation applications must include a deposit for each vacation.
Larger deposits or full payment are also accepted. Please direct all applications and payments to Vacations Services.

For scheduled payments or guest assistance, please contact the Manager of Vacation Services at 1.866.362.6810 ext. 3304

Authorization
Permissions:
I permit pictures and video taken on vacation to be used by Christian Horizons for general and educational promotion. / □ Yes / □ No
I permit the guest to make collect phone calls to this number: ( ) / □ Please do not call unless urgent
Guest/Traveller Waiver
Any vacation carries along with it the risk of injury to me as a person or damage to my property. I, the undersigned, understand
I am a prospective participant of a Supported Vacation at my own risk and I release Christian Horizons and its agents from all liability
for any injury to me or damage to my property that may result from any cause whatsoever.
I am advised that I can call Christian Horizons to find out about the possible risks or damages on the proposed tour that I have
requested before I sign this agreement and until departure.
I understand that if I have to be sent home from an excursion or tour for behavioural or medical reasons, that I am, responsible for the return cost, any associated expenses and that my vacation fees will not be reimbursed. Individuals sent home because of support-related concerns or inappropriate behaviour will receive a pro-rated refund minus deposit and non-refundable pre-paid expenses.
I confirm that all information provided is accurate and complete to the best of my knowledge. The guest is non-violent and able
to vacation in a group setting. The guest has been consulted and informed about the vacation and they have chosen to spend
their vacation time in this way.
I hereby give my consent for the staff involved to secure MEDICAL EMERGENCY care for in the event that it is needed while he/she is on vacation with Christian Horizons. The medical information that I have provided may be used in the event of an emergency. I give full consent to the staff supporting this guest to share information with medical professionals, insurance providers and any other professionals pertaining to the situation. Neither Christian Horizons, nor its employees, will be liable for any financial costs arising from the emergency care.
Guest’s Signature (when possible) / Date / Support Provider’s Signature / Date
Name in Print / Name in Print
Use a separate page for further information that may be helpful in providing proper care, assistance and support to guest.
Cheques should be made payable to Christian Horizons and must be accompanied by documentation (application or attachment). Deposits are non-refundable unless the registration is not accepted or there are no openings available, in which case the full deposit will be returned.
If you wish to cancel your vacation, you must notify Christian Horizons Vacation Services (failing to send the balance of your
fees does not constitute cancellation). Written cancellation of at least 60 days prior to vacation commencement, or cancellation
due to illness, with a supporting medical certificate, will receive a full refund, minus deposit and non-refundable pre-paid
expenses (e.g. airline, train, bus fares, or similar support-related costs).
Completed application and Deposit may be sent to:
Christian Horizons Vacation Services
25 Sportsworld Crossing Rd
Kitchener ON N2P 0A5
Fax: 519-650-8984

Phone: 519-650-0966

ax 519.650.8984