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Every person has a story

ARCh Camp Pow Wow is a true summer camp experience full of laughter, friends, and plenty of fun in the sun! At ARCh Camp Pow Wow, every person has a story, whether it is about where they have been, where they are, or where they would like to go. We think these stories are made to be told! This summer at ARCh Camp Pow Wow, campers will be encouraged to explore their own stories in addition to diving into some classic (and not-so-classic) literary worlds throughout history! Campers and staff will take a page from their favorite books, playing games, creating crafts, and living the lives of their literary heroes. Of course, no summer at camp would be complete without plenty of adventure – hiking, fishing, singing songs, and making a ton of new friends!

Every person is welcome

As the only camp in the area that does not turn campers away, ARCh Camp Pow Wow welcomes children and adults with learning disabilities, cognitive challenges, autism spectrum disorders, physical health difficulties, and a variety of other diagnoses. Some campers use wheelchairs, walkers, or other devices to enhance mobility, while others require a regimen of medications or diligent monitoring of blood sugar. Our Health Services Team includes a Registered Nurse who happily attends to any of our campers’ medical needs. In addition, our dedicated staff includes certified First Responders and counselors trained in non-violent crisis intervention to ensure that campers can have a carefree summer camp experience. Parents and caregivers can breathe easy knowing their loved ones are in a safe and healthy environment.

Developing new pages

ARCh Camp Pow Wow provides a summertime opportunity to maintain progress made through special education and therapy. Kids (age 5 – 21) thrive in an atmosphere where they maintain gains in fine and gross motor skills, speech and language, and socialization. Adult campers (age 22+) enjoy the chance to make new friends and challenge themselves to develop new skills and interests.

This summer, campers and their families will have an opportunity for additional respite! Our “ExtendedHours” program allows campers to be dropped offbefore the regular camp day begins, and/or picked up after the regular camp day ends. Campers participating in this program will be provided a snackat the end of the camp day before participating in some additional exciting camp activities. Check out the Frequently Asked Questions on page 3 in this registration packet for additional information!

It’s your story to write! Tell your own story this summer by exploring the world around you, cooking food grown in our very own garden or staying overnight in a tent under the stars. Join us as we weave a tale of new friends, new experiences, and the most fun you’ve ever had! You’ll want to read it cover to cover!

Our 2013 Summer Theme: Tell me a Story

Tell me a Story

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Our StoryAs told by parents and caregivers of our campers . . .

“Camp Pow Wow has been a lifesaver for our family. My son looks forward to coming all year round!”

“It is impossible for her to express her feelings all the time, but we can tell by her smile that she couldn’t be happier!”

“Andrew is happier after camp. He is not as upset over little things and it is easier to get him to do things for himself.”

“Kristy has been attending camp for 40 years and loves it more than any other activity. It’s better than Christmas for her!”

“It gives Jared the opportunity to meet new friends and socialize, grow, and gain independence.”

“She was so PROUD! Overnight with bonfire and dancing made her feel like a regular kid! Overnighting was a huge opportunity for her…and the first time we were alone in our house overnight in 18 years!”

“He’s already asking to do it again next year…this from a kid who never wants to participate!”

“It’s the only time that we don’t have to struggle in the morning to get out of the house!”

“Derek loved being with kids his own age and this camp allowed for him that important experience that all kids need and deserve. He is learning to trust more people to help him.”

“He’s okay with most situations in new places because of his Camp Pow Wow experiences…his level of independence has blossomed from being at camp!”

“Summers are usually very stressful for myself and his two sisters. Having him at a camp where there was a schedule, and then getting to be home with the girls was really great for all of us. Loved how he was able to bring fishing gear and worms and spend time doing his very favorite activity!”

“It’s not summer without Camp Pow Wow!”

Schedules Matter! A typical day at ARCh Camp Pow Wow provides a safe and comfortable routine through rotations to different activities (art, music, recreation, and life experiences) along with the thrill of meeting special guests and visitors that change from week to week.

Here is an example of what your camper would enjoy on a day filled with fun in the sun!

Day Camp SamplE SChEDulE

9:00 Opening Circle 9:20 Arts & Crafts – Make Pinatas 10:00 Music 10:40 Recreation –Parachute Games 11:20 Lunch (bag lunch brought by camper) 12:00 Life Experiences –Bake cake with homemade frosting 12:40 Free Play 1:20 Swim 2:40 Closing Circle 3:00 Departure

RESIDEntIal Camp SamplE SChEDulE

7:30 Reveille 8:00 Breakfast –French toast, cereal, fruit, milk, juice 9:00 Opening Circle 9:30 Arts & Crafts -Make Bird Feeders 10:30 Fishing 12:00 Lunch –Deli sandwiches, chips, carrots, apples, pudding, juice 12:45 Rest 1:30 Swimming 3:00 Special Guest –Lannon Fire Department 4:00 Free Play 5:00 Dinner –Barbeque chicken, mashed potatoes, beans, fruit salad, corn bread, cookies, juice 6:00 Evening Activity –Capture the Flag 7:30 Shower Hour 8:15 Campfire 9:00 Bedtime

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how can my camper participate in the

Day Camp program when I work from

8:30 a.m. to 5:30 p.m. every day?

Campers may sign up for the Extended Respite option and be dropped off at camp as early as 8:00 a.m., and picked up as late as 6:00 p.m. during day camp weeks. Campers who utilize part, but not all of the Extended Respite hours may still be eligible for partial camp bus transportation. Please contact the ARCh office at (262) 542-9811 to discuss your schedule. The fee for the Extended Respite option is $150 per session, in addition to the regular camp fees.

If

does my camper have to stay the entire

time if I sign up for the extended respite

program?

No! If you are signed up for Extended Respite, you may drop off your camper anytime after 8:00 a.m., and pick them up anytime before 6:00 p.m. However, if you are picking up your camper early, we ask that you please notify the camp office at the beginning of the day so that your camper will be ready for you when you arrive. Otherwise, they may be on a hike, swimming at the beach, fishing at the pier, etc.

What will campers in Extended Respite

do with their extra time in camp?

Campers participating in Extended Respite will still enjoy all of the activities of the typical camp day with everyone else, but they will have additional supervised activities before and after camp. They might go for a hike, make an art project, go for a swim, go fishing, play a game of kickball, make cookies, or do any number of fun camp activities. Additionally, ARCh Camp Pow Wow will provide a daily snack for Extended Respite participants, shortly after the typical camp day ends at 3:00 p.m.

Who can attend camp?

ARCh Camp Pow Wow accepts all campers, regardless of their label of disability. • Children’s sessions are for campers age 5-21 • Adult sessions are for campers who are 22 and older

Where is aRCh Camp pow Wow?

We are located in Menomonee Park, W220 N7884 Town Line Road (Hwy V), Menomonee Falls. We are delighted to partner with the Waukesha County Department of Parks & Land Use to offer camp in a beautiful natural setting complete with hiking trails, lake and wildlife!

What are the hours for day camp?

The typical camp day is from 9:00 a.m. – 3:00 p.m.

Frequently asked QuestionsARCh Camp Pow Wow Information

Tell me More!

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More . . . Tell me More! Frequently asked Questions • ARCh Camp Pow Wow Information

how do I get to camp?

Transportation is provided at no cost from pick-up points throughout Waukesha County, for day camp sessions ONLY. Wheelchair-accessible transportation is available upon request. No transportation is provided for campers participating in Residential Camp. Partial transportation may be available for campers participating in Extended Respite. Contact ARCh at (262) 542-9811 for further details. See PAGe 11 FOr FuLL TrAnSPOrTATiOn DeTAiLS

What is Day Camp like?

Each week of day camp is planned around a theme, and features special activities and visitors. Camp activities include arts and crafts, music, recreation, life skills such as cooking and gardening, fishing, swimming, kayaking, and much more! The camp day begins at 9:00 a.m. and ends at 3:00 p.m. Campers must bring their own lunch to day camp sessions. The camper-to-staff ratio for Day Camp sessions is 3:1.

What is Residential Camp like?

Residential camp is five full days of overnight respite camp. Campers arrive at 9:00 a.m. on Monday, and leave at 3:00 p.m. on Friday. Campers spend their nights

in platform tents and participate in all of the usual campactivities during the day – crafts, fishing, games, music, and of course, plenty of swimming at the nearby beach! This allows for a more rustic camp experience and more individualized attention. Of course, our campers have full access to our air conditioned lodge, complete with modern bathrooms, showers, and a full kitchen. No transportation is provided for residential camp. The camper-to-staff ratio is 2:1 during residential camp.

are there overnights at Camp pow Wow?

During Day Camp sessions, we offer an optional Thursday night overnight experience at no additional cost. Campers and staff enjoy a night in platform tents, featuring special all-camp activities and a rowdy campfire.

PLEASE NOTE: Transportation is not provided on Thursday afternoons or Friday mornings for Day Camp sessions. If your camper is not spending Thursday night at camp, the parent/caregiver is responsible for arranging transportation on Thursday afternoon at 3:00 p.m. and Friday morning at 9:00 a.m.

Additionally, Residential Camps include four overnights, as campers stay at camp from Monday through Friday.

how much does camp cost?

• Day Camp per session (week), including transportation . . . . . . . . . . . . . . . . . . . . $350 • Extended Respite program per session (week) of Day Camp . . ADDiTiOnAL $150 • Residential Camp per session (week) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $700 PlEAsE NotE: camp rates differ if registration fees are being paid by a third party. See PAGe 18 FOr MOre inFOrMATiOn

Who can I talk to if I have more questions about aRCh Camp pow Wow?

Please contact the ARCh office for more information.• Call 262-542-9811 -or- e-mail archcamppowwow@ameritech.net

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adult Sessions junE 17 - 21 • SESSION 1DAy CAmP ’midsummer night’s Dream’A camp by any other name would smell as sweet! The curtain goes up on a true theatrical adventure as you travel back to the Renaissance this week to experience a little piece of Shakespeare’s world. It’s up to you to pick your role – king, queen, jester, or knight – all are welcome at ARCh Camp Pow Wow! Act quickly, but be sure to leave your tights at home. After all, you don’t want to make a scene!

july 15 - 19 • SESSION 4 DAy CAmP ’Color War’1, 2, 3, 4, We want color war! 5, 6, 7, 8, What is it gonna take? No Color War protests needed here. Camp will be split into two teams as campers and counselors alike compete in a five-day adventure to win points. Campers will earn points for participating in a variety of activities including a kayak race, tie dye contest, all-camp musical chairs, and everybody’s favorite, “All Pow Wow’s Children.” Then, get ready on Thursday night for the 3rd annual ARCh Camp Pow Wow S’Mores Cook-off, followed by Friday’s events – the pie toss, and the song competition at closing circle. Spirit and pride are all around as you compete for the title of 2013 ARCh Camp Pow Wow Color War Champions!

july 29 - auguSt 2 • SESSION 6 RESIDENTIAL CAmP ’Folktales and Fables’ Have you ever wondered about what it might be like to be a part of a different culture? Taste the food, play the games, and make traditional art? Experience the traditions, stories, sights, and sounds of world cultures in this exciting week at ARCh Camp Pow Wow! You will spend your nights in a unique platform tent after a fun-filled day of swimming, fishing, art projects, sports, picnics, and much more! Enjoy a week-long overnight camping experience from Monday through Friday featuring a 2:1 staff ratio. You won’t want to miss it!

COlORWaR!

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children's Sessions junE 24 - 28 • SESSION 2RESIDENTIAL CAmP ’Sherlock holmes & the Case of the Curious Camper Caper’ Whodunnit? Elementary, my dear Watson! Join us in this fun and exciting week of cases, clues, mysteries, and magnifying glasses. Campers will spend their week playing detective, finding clues, and solving the biggest mystery of the summer – Who was the criminal mastermind behind the Curious Camper Caper? Just don’t be fooled by any red herrings! You will spend your nights in a unique platform tent after a fun-filled day of swimming, fishing, art projects, sports, picnics, and much more! Enjoy a week-long overnight camping experience from Monday through Friday featuring a 2:1 staff ratio. You won’t want to miss it!

july 8 - 12 • SESSION 3 DAy CAmP ’Once upon a time’ once upon a time, there lived entire castles full of princesses, dragons, fairies, and of course, several very charming princes. One week, everyone in the kingdom gathered in the faraway land of ARCh Camp Pow Wow to make their dreams come true. They sang songs, made crafts, played games, cooked some delicious food, and even went for a kayak ride on the lake! Everyone had so much fun that at the end of each day, they didn’t want to leave the magical land of ARCh Camp Pow Wow. In fact, one day they even decided to stay there overnight – and they had the best time! Although they were sad that they had to leave at the end of the week, they still had their memories and their stories to share with their friends and families. And they all lived happily ever after!

july 22 - 26 • SESSION 5 DAy CAmP ’Seussecamp the Day Camp’Camp kids and their parents all gathered around to hear the most peculiar story in town of a place called Camp Pow Wow that is sure to astound! The counselors are Whos and the director’s a clown! The kids laughed and they shouted – “All right, all right! Why WOuLDn’T you want to make your own kite? Come one, and come all, who think that they might – try ‘Green Eggs and Ham’ on the overnight! Will they fish, will they hike, will they ride the canoe? What fun! What fun! They’re searching for Whos! The singing of songs and the crafting with glue – at Seussecamp the Day Camp, there is so much to do!”

auguSt 5 - 9 • SESSION 7 DAy CAmP ’Superheroes: From Ordinary to Extraordinary’ It’s a bird! It’s a plane! It’s super Camper! Discover where your powers lie, and be like your favorite superheroes this week. You’ll make a cape, design your ride, and discover that anyone can be a superhero to our friends in need. Meet some real-life heroes and take your superpowers from ordinary to extraordinary in this action-packed week filled with fun and adventure!

auguSt 12 - 16 • SESSION 8 DAy CAmP ’Color War’ 1, 2, 3, 4, We want color war! 5, 6, 7, 8, What is it gonna take? No Color War protests needed here. Camp will be split into two teams as campers and counselors alike compete in a five-day adventure to win points. Campers will earn points for participating in a variety activities including a kayak race, tie dye contest, all-camp musical chairs, and everybody’s favorite, “All Pow Wow’s Children.” Then, get ready on Thursday night for the 3rd annual ARCh Camp Pow Wow S’Mores Cook-off, followed by Friday’s events – the pie toss, and the song competition at closing circle. Spirit and pride are all around as you compete for the title of 2013 ARCh Camp Pow Wow Color War Champions!

COlORWaR!

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JULY

16

MARCH

29

Ready for the Summer of a lifetime? Here’s how to make it happen!

how do I register for camp?

It’s easy! Simply complete the camp registration forms, pages 10-18, along with a $50 per session deposit, and return to the ARCh office by Friday, March 29th. Registrations received after this date will be assessed a $25 per session late fee. Don’t forget to include the deposit of $50 per session to hold your spot(s). registration deposits are not refundable.

Once your registration is received, you will receive a confirmation along with your camp invoice.

Full payment of all fees and completed Health Examination Form are due by Friday, April 19th. Please make sure to register early to ensure you can attend all the sessions you want! Camp is in high demand; therefore, no camper will be permitted to attend camp until ALL FEES AND COMPLETED FORMS HAVE BEEN RECEIVED BY ARCh. Once all forms are submitted, you will receive a packing list, bus schedule and other important information to help make your time at camp successful and unforgettable!

Will I become a member of aRCh when I register?

In addition to camp fees, all campers are required to be members of ARCh, which entitles you to access a variety of additional programs and services. (See page 9 for a description of the many benefits of membership in ARCh!) If you are new, or due to renew, your membership fee will be added to your camp invoice. (Membership cost is not included in camp fees.) Annual membership fees are $50 for a family membership, or $10 for an adult with a disability living in an assisting living environment.

What if I want to cancel my registration?

Refunds for cancellations, less the $50 nonrefundable deposit per session, are only available until Friday, April 19th. No refunds will be issued after this date, except in cases of documented medical emergencies. The $50 deposit is not refundable under any circumstances.

CAmP REgISTRATION FORmS ARE ALSO AvAILAbLE ON OuR WEbSITE:

www.waukeshaarch.org

RETuRN FORmS AND DEPOSITS TO: ARCh

419 Frederick StreetWaukesha, WI 53186

DEaDlInE FOR:

• Registration Forms

• Deposits

DEaDlInE FOR:

• Health Exam Forms

• ALL REmAININg FEES DuE

STARTS!!!

vISITORS NIgHTPlease join the fun!

Important Dates to Remember

APRIL

19JUNE

17

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A word about FundingyOu Could be a hero!Here’s how to make it happen!

Give a Campership impact a life . . . Sponsor a campership!

Many children and adults with disabilities lack the financial resources to attend camp. Children may come from homes undergoing financial stress. Adults working in sheltered employment often earn just $60 per month. You can make a dream come true by sponsoring a campership! Your gift in any amount will help to make camp possible for someone who, without your help, could not participate.

A gift of $350 provides one week of camp for a delighted camper, but any amount makes an impact!

If you would like to help a deserving individual have an unforgettable experience, please indicate your sponsorship of a campership on pages 16 - 17. on behalf of many grateful children and adults, thank you for your kindness!

how to apply for campership funding

ARCh continually strives to keep camp fees as low as possible. We charge only a portion of the full cost of camp, and subsidize the rest through agency fundraising activities. Many of our campers have fees paid in part or in full through a third party, such as a social service agency.

The ARCh Campership Fund provides assistance only in cases of greatest financial need. Camperships are for Day Camp only, NOT Residential Camp.

Requests for a Campership Application must be in writing. Please submit your written request by mail to:

ARCh, 419 Frederick Street, Waukesha, WI 53186 or via e-mail to archoffice@ameritech.net

Campership applications are due Friday, march 29th – NO EXCEPTIONS.

The Campership Committee will announce campership award decisions on or before Friday, April 12th.

Other Sources For Funding assistance If you require financial assistance, you may wish to seek other sources of funding. Limited funding may be available to support respite care. Also, a variety of waiver agreements and programs, as well as long-term family support dollars, assist in providing financial resources for camp. For this and other options, contact your county Department of Health & Human Services and/or your managed care organization to determine whether you are eligible. Or call the Respite Care Association of Wisconsin (608-222-2033 or 866-702-7229).

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Welcome to the family! AssociAtion for the Rights of citizens with handicaps

Want mORE? Check out our• Community presentations about acceptance of differences! • Faculty in-services on disability-related issues!

• Workplace trainings on diversity awareness and inclusion! We are here to serve our members, so please let us know what you need and how we can help! Contact us by phone (262) 542- 9811 or e-mail archoffice@ameritech.net

We were founded in 1952 by Waukesha County parents who had a vision: a world in which their children with disabilities would be valued and encouraged to contribute. Decades later, we remain true to that dream and dedicated to providing a unique array of programs and services that change lives by: • Helping children and adults with disabilities increase skills and self-confidence so they can pursue their dreams; • Providing support and resources to parents that help them sleep easier at night; • Educating the community about the capabilities of all people through dynamic presentations for schools, civic organizations and workplaces.

ARCh proudly offers an award-winning youth leadership team, an advocacy program that assists parents and children in navigating through the often-complex education and adult service systems, “mini camp” for kids during school breaks, clubs and classes that teach young adults about safety and positive choices, community-based outings and activities, and a trust program that helps parents plan for a secure financial future for their child. In 2010, ARCh was honored to be recognized by the Waukesha County Executive as the Small Nonprofit of the Year!

When you register for camp, you become a member of ARCh and gain access to services like these:

aRCh for paREntS: • Advocacy – Information and resources on medical care, benefits, transportation, housing, etc. along with emotional support and self-advocacy training. Advocacy services include support for IEP meetings, staffings, and 504 meetings.

• ARCh Life Needs Trust – A safe plan to ensure the future financial security and happiness of your child.

• T.A.G. – Transition Advisory Group – Support for parents/ caregivers with children in transition (high school to the adult world, grade school to high school, early childhood to school, etc.), providing monthly sessions on topics requested by parents.

aRCh for yOung aDultS (ages 13-21): • Teen Time – Service projects and community outings for teens with and without disabilities to build friendships and social skills.

• True Beauty Club – A group for girls and young women to learn about body image, self-confidence and positive choices, in order to keep them safe and healthy.

aRCh for aDultS (age 18+): • Thursday Night Socials – Twice-monthly dances for approximately 150 energetic participants.

• Small Group Activities – Outings in the community to sporting events, plays and movies, along with great activities like cake decorating, dance classes, and day trips to Chicago, Green Bay and other exciting destinations! 60 years and going Strong …for yOu!

aRCh is celebrating 60 years of making a difference!

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Camper Information Form COmplEtE & REtuRn By FRIDay, maRCh 29, 2013

Camper Information

Last Name:_________________________________________ First Name:__________________________________

Address:_______________________________________________________________________________________

City:_______________________________________________ State:____________ Zip: _____________________

Date of Birth:_______________________________________ Attended CPW before? ____YES ____NO

T-shirt size: (Please Circle One)

Youth: 6/8 10/12 14/16 18/20

Adult: S M L XL XXL

With whom should we communicate to coordinate camper’s program?____Parent/ legal guardian ____Group home manager, caseworker, etc.

Confirmation materials will be sent here.

Name:_____________________________________________ Relationship: _______________________________

Address:_______________________________________________________________________________________

City: ______________________________________________ State:_________________ Zip:_________________

Day Phone: ________________________________________ Evening Phone: ______________________________

E-mail: (For use by ARCh only) _____________________________________________________________________

PlEAsE NotE: Most camp information will be sent to you via email.

Emergency Contact InformationIT IS MANDATORY THAT WE HAVE TWO (2) CONTACTS

1ST CONTACT: Name:____________________________________ Relationship: _____________________________

Phone Number: ____________________________ Alternate Phone Number: _____________________________

2ND CONTACT: Name:____________________________________ Relationship: _____________________________

Phone Number: ____________________________ Alternate Phone Number: _____________________________

For your convenience, keep the first half of this packet (pages 1-9) for your reference, andreturn the second half (pages 10-18) of your camp registration with deposit payment(s) to:

ARCh, 419 Frederick Street, Waukesha, WI 53186.

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Bus transportation DEaDlInE tO REtuRn: FRIDay, maRCh 29, 2013

plEaSE SElECt yOuR BuS StOp:

All campers (including those who use wheelchairs) can access transportation at any of the stops listed below. All stops listed below will be available for all day camp sessions, with the exception of Thursday nights and Friday mornings. Some stops may have been changed or removed from previous years.

____ DELAFIELD - McDonald’s (I-94 & HWY. 83)

____ OCONOMOWOC – Pick ‘n Save (Plank Road location)

____ MERTON – Hartbrook Mall (by ATM machine)

____ PEWAUKEE – Chase Bank

____ MENOMONEE FALLS – Good Shepherd Church

____ MUSKEGO – I-43 & Racine Park & Ride

____ WAUKESHA – Fox Run Shopping Center (by True Value)

____ WAUKESHA – Old Walmart lot (Hwy. 164 S. & Coral Drive)

____ BROOKFIELD – Ruby Isle (by Walgreens)

____ BROOKFIELD – Zion Church (Brookfield & Lisbon Roads)

Remember to indicate above if you need wheelchair-accessible transportation at your pick-up point.

bus Transportation to ARCh Camp Pow WowDEaDlInE tO REtuRn: FRIDay, maRCh 29, 2013

The final bus schedule will be mailed prior to your camper attending camp.

BuS tRanSpORtatIOn IS pROvIDED FOR Day Camp OnlyNO transportation provided for Residential Camp.Extended Respite participants should contact the ARCh office for transportation information - (262) 542-9811.

plEaSE ChOOSE yOuR tRanSpORtatIOn plan:

____ PLAN #1: We will provide our own transportation for our camper.

____ PLAN #2: We will use ARCh transportation to/from a stop listed below.

____ Check here if camper will use ARCh transportation and requires a wheelchair-accessible bus.

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All about ME! DEaDlInE tO REtuRn: FRIDay, maRCh 29, 2013

All important information regarding the camper’s health and well-being should be on the following forms. Do not rely on verbal instructions to communicate information about your camper. Please answer questions as completely as possible to enhance your camper’s success at ARCh Camp Pow Wow. Feel free to attach additional information to these pages. The more information we have about your camper, the better their experience will be.

PLEASE INCLuDE A PHOTO OF yOuR CAmPER FOR OFFICE uSECamper’s Name: __________________________________________________ Date of Birth: ____________________________

Camper lives with: __________________________________________ Goes to school/work at: ____________________________

Camper’s disability is called: _________________________________________________________________________________

Please indicate any allergies here: _____________________________________________________________________________

________________________________________________________________________________________________________

Seizure Disorders: ____ Does Not Apply ____ Non-convulsive (Petit mal)

____ Nocturnal ____ Tonic/Clonic (Grand mal)

____ Psychomotor ____ Mixed

Seizure Frequency: ______________ Length of seizure: _____________

Date of last seizure: ______________

How are seizures handled at home? _____________________________

__________________________________________________________

__________________________________________________________

mobility: (indicate all that apply to the camper)

____ Ambulatory

____ Walker/crutches

____ Stroller

____ Cane

____ Braces

____ Prosthesis

____ Manual Wheelchair

____ Power Wheelchair

Additional Comments: ________________________________________________________________________________________________________________________________

Transfer Information:

____ Independent

____ Standby Assistance

____ Pivot (1 person)

____ Two-person

Other/comments: _______________________________________________________________________________________________________________________________________________________________________

ContinueD on PAge 13

• SPECIAL DIETS: Menu will be sent to all campers prior to attending camp.

• G-TUBES: We can usually accommodate a G-tube schedule. Please attach the feeding schedule so we can contact you with any questions prior to attending camp. Please call ARCh at 262-542-9811 with any further questions.

Eating:Normal appetite: ____Large ____Medium ____Small

Diet: ____Standard ____Chopped Food ____Blended/pureed

____G-tube Other: ______________________________ ___________________________________

Is camper able to indicate the amount of food and liquid intake he/she needs? ____ Yes ____ No

Eating accommodations: Camper able to feed self with:

____ Needs total assistance ____ No help

____ Straw ____ Some assistance

____ Clothing protector

____ Adaptive utensils

Special Instructions (attach separate paper if necessary): __________________________________________________________________________________________________________________

PAgE 1 OF 2

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More . . . All about ME! DEaDlInE tO REtuRn: FRIDay, maRCh 29, 2013

CONTINUED FROM PAGE 12 • PAgE 2 OF 2

Toileting: Please bring all needed supplies/equipment, (e.g. briefs, wipes, etc.) to each camp session.

Is camper independent in toileting? ____ Yes ____ No

Does camper wear disposable briefs? ____ Yes ____ No If yes, how often changed? _________________________

Toileting instructions or other accommodations: ________________________________________________________________

Personal Hygiene: Please complete this chart by writing an “X” and comment where appropriate.

Communication: ____ Verbal

____ Non-verbal

____ Sign-language

____ Gestures

behavior: *If the camper has a behavior plan or IEP available, please include a copy.If the camper becomes upset, you may see (mark all that apply):

____Verbally Aggressive Behaviors

____Physically Aggressive Behaviors

____Shouting

____Swearing

____Self-Abusive Behaviors

____Tendency to Withdraw

Swimming Skills: (check all that apply)

____Has taken swimming lessons ____Can float (with or without device)

____Likes the water ____Doesn’t like the water

Please provide additional instructions or explanations for our aquatic services staff:______________________________________________________________________________________________________________________

Additional Information: Please describe any likes, dislikes, fears or habits that you think would be helpful for the Camp Pow Wow staff to know. (If there is not enough room, please attach separate paper and return with this form.) ___________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Dressing

Undressing

Showering

Washing face/hands

Brushing hair

Brushing teeth

Menstrual Care

TOTAL ASSISTANCE SOME HELP SUPERVISE REMINDERS INDEPENDENT

When upset, the best ways to calm or soothe the camper are: __________________

____________________________________________________________________

____________________________________________________________________

What motivates the camper? ____________________________________________

____________________________________________________________________

____________________________________________________________________

Does the camper understand/respond to questions? ____ Yes ____ No

Does the camper communicate his/her needs and wants? ____ Yes ____ No

Does the camper read/write? ____ Yes ____ No if yes, at what level? ______________________

Additional Instructions: _____________________________________________________________

Communication device used? ________________________________________________________

Sleeping: Please describe any special instructions for bedtime / the overnights:

__________________________________

__________________________________

__________________________________

__________________________________

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Health Examination FormWisconsin State Law requires all campers to have an annual physical exam.

hEalth FORmS DuE By: apRIl 19, 2013PAgE 1 OF 2

Parent/guardian Section:Camper’s Name: __________________________________________________ Date of Birth: ______/______/______

Health Insurance Provider: ________________________________________________________________________

Health Insurance Number: ________________________________________________________________________

Name of Insured: ___________________________________ Relationship to Camper: ________________________

In the event of a medical emergency, when it is not possible to contact the parent or guardian, I grant the Association for the Rights of Citizens with handicaps (ARCh) permission to contact appropriate medical personnel and authorize medical service or emergency treatment to the camper named above.

X_____________________________________________________________ Date: _________________________ (Signature of Parent or Guardian)

The remainder of this form must be completed by a licensed medical physician, PA or RN.

To be filled out by Health Care Professional:

Examined on: ________________ Medical Diagnosis: _________________________________________________Gender: _________ Age: ___________ Weight: __________ Height: ___________ BP: _____________________

Is the following normal?(YES or NO). if nO, please explain: 1. Ears: ____________________________________ 8. Lungs: _____________________________________ 2. Nose: ___________________________________ 9. Extremities: __________________________________ 3. Throat: _________________________________ 10. Glands: _____________________________________ 4. Skin: ___________________________________ 11. Abdomen: __________________________________ 5. Eyes: ___________________________________ 12. Varicosities: __________________________________ 6. Scalp: __________________________________ 13. Genitalia: ___________________________________ 7. Heart: __________________________________ 14. Neurological: ________________________________

Is there a history of (YES or NO). if yeS, please explain: 1. Asthma: _________________________________ 8. Stomach Disorder: ____________________________ 2. Hernia: _________________________________ 9. Heart Disease: _______________________________ 3. Enuresis: ________________________________ 10. Frequent Colds: ______________________________ 4. Recent Fevers: ___________________________ 11. Hay Fever: __________________________________ 5. Recent weight loss: _______________________ 12. Hepatitis: ___________________________________ 6. Kidney Disease: ___________________________ 13. Other bodily fluid precautions, specify: ____________ 7. Diabetes: _______________________________ ___________________________________________

if yeS to diabetes, please indicate frequency of blood 14. Other history: _______________________________ glucose checks and any needed snacks according to __________________________________________ blood sugar levels: __________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________

Does camper require G-tube feedings?________ If yes, please indicate product, amount and frequency: ____________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

sEE NExt PAgE

15

Health Examination FormWisconsin State Law requires all campers to have an annual physical exam.

hEalth FORmS DuE By: apRIl 19, 2013

PAgE 2 OF 2 hEalth FORmS DuE By: apRIl 19, 2013Does this person have seizures or convulsions? ____ Yes ____ No If yes, type? _________________________________________________________________________________________ Frequency: ___________________________________________________ Last Seizure: __________________________ Treatment: __________________________________________________________________________________________

Does this person have allergies? ____ Yes ____ No If yes, what type? _______________________________________ __________________________________________ _______________________________________ __________________________________________ _______________________________________ __________________________________________

Please list any medications camper is currently taking:

Please note: ONLY medication on this list will be administered to camper at Camp Pow Wow, so please take time to properly complete. Any changes in medications between the time of this physical and when the camper attends camp, must be authorized again by signature of a licensed medical physician, PA, or RN.

Permission to give camper over-the-counter medication: ____ Yes ____ No

Diet Restrictions: _________________________________________________________________________________________________________________________________________________________________________________________________________

Additional Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If this space is not sufficient, please attach an additional sheet/s of notes or care instructions that may be helpful to our Health Services Staff.

_____________________________________________________________________ Phone: __________________________ (PLEASE PRINT) Name & Credential of Medical Professional

X_____________________________________________________________ Date: ___________________________ Signature of Medical Professional

Please circle which are permissible: Pepto Bismol Aspirin Tylenol Antacid Cough Syrup Decongestant Benadryl Kaopectate

Has the camper been immunized against the following: (provide most recent dates if possible) ___ Polio: _____________ ___ Measles: ______________ ___ Mumps: ___________ ___ Hepatitis B: ____________ ___ Rubella: ___________ ___ Tetanus: _______________

TIME OF REASON FOR SIDE EFFECTS MEDICATION DOSAGE DELIVERY MEDICATION TO WATCH FOR

16

adult Registration Form REgIStRatIOn DEaDlInE: FRIDay, maRCh 29, 2013

Please check appropriate boxes and fill in the amount due for each session you are attending.

aDult Camp SESSIOnS—for campers ages 22 and older SESSION AmOuNT DuE

junE 17 - 21 – SESSION 1 DAy CAmP ‘midsummer night‘s Dream‘ 9:00 a.m — 3:00 p.m. *THURSDAY OVERNIGHT—nO ADDiTiOnAL ChArGe ____ Yes ____ No

Extended Hours —8 a.m. - 6 p.m. ____ Yes ____ No $150 $_________

july 15 - 19 – SESSION 4 DAy CAmP ‘Color War‘ 9:00 a.m — 3:00 p.m. *THURSDAY OVERNIGHT—nO ADDiTiOnAL ChArGe ____ Yes ____ No

Extended Hours —8 a.m. - 6 p.m. ____ Yes ____ No $150 $_________

july 29 - auguSt 2 – SESSION 6 RESIDENTIAL CAmP ‘Folktales and Fables‘ 9:00 a.m. Monday — 3:00 p.m. Friday

total $__________

Third party cost(s) if applicable. (see “Payment options” on page 18 ) + $__________

LATE FEE for registrations reCeiveD After MArCh 29, 2013 - ADD $25 per session + $__________

sub total $__________

Payment enclosed with this registration (minimum of $50 per session) DEDuCT payment - $__________

REmaInIng BalanCE DuE $__________

I / we would like to sponsor a campership. Yes, i want to be a hero! + $__________

paymEnt DuE In Full by FRIDay, apRIl 19, 2013 $__________

* DAy CAmP REmINDER: NO transportation provided on Thursday afternoons & Friday mornings.

$350 $_________

$350 $_________

$700 $_________

17

child Registration Form REgIStRatIOn DEaDlInE: FRIDay, maRCh 29, 2013

Please check appropriate boxes and fill in the amount due for each session you are attending.

ChIlDREn‘s Camp SESSIOnS—for campers ages 5 — 21 SESSION AmOuNT DuE

junE 24 - 28 – SESSION 2 RESIDENTIAL CAmP ‘Sherlock holmes and the Case of the Curious Camper Caper‘ 9:00 a.m. MONDAY — 3:00 p.m. FRIDAY

july 8 - 12 – SESSION 3 DAy CAmP ‘Once upon a time‘ DAy CAmP 9:00 a.m — 3:00 p.m. *THURSDAY OVERNIGHT—nO ADDiTiOnAL ChArGe ____ Yes ____ No Extended Hours —8 a.m. - 6 p.m. ____ Yes ____ No $150 $_________

july 22 - 26 – SESSION 5 DAy CAmP ’Seussecamp the Day Camp’ 9:00 a.m — 3:00 p.m. *THURSDAY OVERNIGHT—nO ADDiTiOnAL ChArGe ____ Yes ____ No Extended Hours —8 a.m. - 6 p.m. ____ Yes ____ No $150 $_________

auguSt 5 - 9 – SESSION 7 DAy CAmP ‘Superheroes: From Ordinary to Extraordinary‘ 9:00 a.m — 3:00 p.m. *THURSDAY OVERNIGHT—nO ADDiTiOnAL ChArGe ____ Yes ____ No Extended Hours —8 a.m. - 6 p.m. ____ Yes ____ No $150 $_________

auguSt 12 - 16 – SESSION 8 DAy CAmP ‘Color War‘ 9:00 a.m — 3:00 p.m. *THURSDAY OVERNIGHT—nO ADDiTiOnAL ChArGe ____ Yes ____ No Extended Hours —8 a.m. - 6 p.m. ____ Yes ____ No $150 $_________

$700 $_________

$350 $_________

$350 $_________

$350 $_________

$350 $_________

total $__________

Third party cost(s) if applicable. (see “Payment options” on page 18 ) + $__________

LATE FEE for registrations reCeiveD After MArCh 29, 2013 - ADD $25 per session + $__________

sub total $__________

Payment enclosed with this registration (minimum of $50 per session) DEDuCT payment - $__________

REmaInIng BalanCE DuE $__________

I / we would like to sponsor a campership. Yes, i want to be a hero! + $__________

paymEnt DuE In Full by FRIDay, apRIl 19, 2013 $__________

* DAy CAmP REmINDER: NO transportation provided on Thursday afternoons & Friday mornings.

18

Payment Options

1) Check or Money Order Enclosed (made payable to ARCh): Check #_______________________ Amount: $________________________

2) Credit Card: Cardholder Name: ______________________________________________________

VISA

Account Number:____________________________________ Exp. Date: __________

MasterCard

Security code (3 digits on back of credit card): _________________________________

Amount to bill to credit card: $ _____________________________________________

Cardholder Signature: ____________________________________________________

3) Third Party Pay: If camp is being paid through county funds (family services, autism waiver programs, etc.) or by another third party, the full cost of camp will be invoiced to the payer. • Full cost of Residential Camp is $800 per camper • Full cost of Day Camp is $450 per camper • Full cost of Extended Respite is $150 per camper (Day Camp ONLY) Third Party Payer Contact Information: Name: ______________________________________ Agency: __________________________________________

Address: _______________________________________________________________________________________

City:________________________________________ State: ___________________ Zip: ______________________

Phone: __________________ Fax:________________ E-mail: ____________________________________________

DEaDlInE tO REtuRn payment Options & Consent Form: FRIDay, maRCh 29, 2013

Consent Parent/guardian Consent

I understand that I am liable for all camp fees, including any fees billed to a third party listed above, in the event that the third party does not pay. I also understand I am liable for camp fees whether or not the camper attends.

I give permission for the camper named on page 10 to attend ARCh Camp Pow Wow and to participate in all activities.I give ARCh Camp Pow Wow permission to use photographs of this camper in ARCh publicity and promotions.I give ARCh Camp Pow Wow permission to transport the camper before, during, and after camp activities. I give ARCh Camp Pow Wow permission to provide routine health care, administer medications, and seek emergency medical treatment.

I agree to relieve ARCh Camp Pow Wow and its personnel from any liability in connection with any ARCh Camp Pow Wow activity.

Print name of Parent/Guardian: _________________________________________________

* Signature of Parent/Guardian: _________________________________________________

*We will only accept the signature of Parent/Guardian

Date: _________________________________________________

Contact information for Parent/Guardian if not included on page 10:

Phone: __________________________ Email: ______________________________________

looking ahead!Next year we will be celebrating

aRCh Camp pow Wow’s

55th summer of friends, laughter & fun in the sun!

We can’t wait to celebrate with you!

STAY TUNED FOR MORE INFORMATION!

419 Frederick StreetWaukesha, WI 53186

PRINTED BY AMERICAN PRINT QUIK, INC. - MENOMONEE FALLS, WI • PHOTOS BY REBECCA BAUER • DESIGN & ILLUSTRATION BY HARTMAN DESIGN & SANDY POENITSCH

Our mission: . . . to empower children and adults with disabilities to reach their full potential, and to increase

prevention and awareness in the community.

2014