Camp #1
2015 Summer Camp Experience Registration #1
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), this notice informs you of the purpose for collection of information on this form. Please read it before completing the form.
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Authority: Title 10 U.S.C. Section 8013, Privacy Act System Notice F044 AF SG U, Special Needs and Educational and Developmental Intervention Services (EDIS), and AFI 33-332, Privacy Act Program, Exceptional Family Member Program (EFMP).
Principal Purpose: Information provided will be used by personnel of the Department of Defense (DoD) to assess eligibility for and manage installation-level EFMP activities and services.
Retention and Safeguards: Paper and electronic records are restricted to authorized personnel with an official need-to-know. Electronic data is maintained in a password restricted case management system and encrypted while at rest and during transmission. Physical access for all records are controlled by locked terminals and rooms, guards, personnel screening, or visitor registers.
Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records may be disclosed outside DoD as a routine use pursuant to the DoD Blanket Routine Uses that appear at http://privacy.defense.gov/notices/blanket_uses.shtml.
Disclosure: Providing information on this form is voluntary, but failure to provide the requested information may result in denial of some EFMP programs and services.
Child’s Name: Shirt Size: ______
(Last) (First) (MI)
Address: ______
(City) (State) (Zip Code)
DOB: ______Age: ______Home Telephone: ( ) ______
Diagnosis: ______
Sponsors Name: ______Military Branch ______
Home#______
Work#______Cell#______Email______
Spouse: ______
Home#______Work#______Cell#______Email______
Emergency Contact Name &Telephone: ______
Special Needs Assessment
1. Does your child have functional speech? ______If not, please describe how they best communicate.______
______
2. Eating habits: Does your child need assistance? ______If so, what kind? ______
Are there any foods to avoid? List here.
______
3. Does your child have any allergies? (Food, medicine, outdoor) ______If so, what kind? ______
What precautions should be taken? ______
______
What steps should be taken in case of exposure? ______
______
4. Does your child have any emotional/behavioral issues or aversions (i.e., transitioning, leaving parent/sibling, loud noises, and balloons)? If yes, please describe.
______
If yes, how are these best handled?
______
5. Can your child use the toilet independently? If no, please list any special assistance needed. ______
6. We will be playing games, using gym equipment, etc. Are there any specific activities or movements that need to be avoided? If yes, please describe. ______
7. Will your child need to use any special equipment at camp (walker, wheelchair, picture schedule, communication board, etc.)? If so, please describe how it should be used.______
8. Does your child take any medications? If yes, please list the name and any side effect.______
______
9. Will your child need to take any medications while at camp? ______If so, please describe what, when, and what dosage. ______
10. Does your child have a history of seizures? ______If so, please describe them and steps to take if your child has a seizure. ______
11. What are your child’s favorite activities and characters?
______
12. What would you like your child to gain from this camp experience?
______
13. Is there any additional information you would like us to know about your child? We’d like to know about your child’s strengths, their successes this year at school and what your family loves about them!
______
Release of Camper
PLEASE PRINT OR TYPE
Campers will be released only to those individuals listed below, upon proof of identity (i.e., valid driver’s license or government issued picture identification).
This includes parent(s) and/or guardian(s).
1. ______
Name: address, phone
2. ______
Name: address, phone
3. ______
Name: address, phone
Photograph(s) and Video Consent
Yes ___ No ___ I hereby give Joint Base Andrews EFMP Summer Camp Experience the absolute right and permission to use and/or publish, and/or reproduce any photographic and/or video likeness of my child, in which he/she may be included in whole or in part, for any official purpose whatsoever. I waive any right that I may have to inspect, and/or approve the finished product or the use to which it may be applied. I hereby release, discharge, and agree to save from liability by virtue of any blurring, distortion, alteration, optical illusion or in composite form, whether intentional or otherwise, that may occur or be produced in the taking of such pictures, or in any processing tending toward the completion of the finished product.
Yes ___ No ___ I hereby give permission for my child’s name to be listed with any pictures/video of him/her.
Name of Camper: ______.
Parent/Legal Guardian Signature: ______,
Date: ______
Hold Harmless Agreement
I,______parent/guardian of ______, in consideration of the U.S. Air Force allowing my child to voluntarily participate in the EFMP Summer Camp Experience program, and in recognition of the possible risks and dangers involved, assume all risks of injury to my child and property that may be sustained, and I do release forever the United States, its agencies, personnel, mentors from every liability arising out of my child’s participation in this activity.
______
Date Signature of Parent or Guardian Printed Name of Parent or Guardian
Please note:
· Bug repellant and sunscreen should be applied to your camper each day of the camp before arrival. Campers will be provided a snack mid-morning.
· EFMP Summer Camp Experience is a FUN experience and welcomes children with special needs however it does not offer a clinical setting. If a camper’s conduct is deemed to be unsafe, harmful to self or others, inappropriate or unmanageable parents or guardians will be called and he/she may need to be picked up.