CAMP

• Camper Rally Night Thursday: September 12 at 6:30 p.m. at the Mesa Convention Center, 263 N. Center Street, Building A, Mesa, AZ 85201. Attendance is strongly encouraged for parents and campers.

• Departure: Thursday, September 19 at 10 a.m. Meet at the Mesa Hohokam Stadium, 1235 N. Center Street Mesa, AZ 85201

• Return: Hohokam Statium, Saturday, September 21 at 5 p.m.

• Meals: A sack lunch is required on Thursday, September 19 for our stop in Payson. All additional meals provided – dinner on Thursday to lunch on Saturday.

• Space is limited to 30 spots per City, please sign up early. Registration will be closed when it is full.

Camp SHADOW PINES Cabins Heber, AZ • Sept. 19-21 This program is designed for teens ages 18 and older with developmental disabilities. The purpose is to explore Arizona’s high country and escape the heat of the summer, gain an appreciation for nature and all of its beauty, learn how to fish, take a hike, or just skip rocks beside a cool mountain lake. Join the fun as Mesa and Chandler go off to the mountains!

For more info, please contact your respective City:

Chandler-Collette Prather(480) 782-2709 Logann Weimers (480) 782-2742

Mesa-Jacquie Gallo(480) 644-4948Josh Underwood(480) 644-5777

Registration DeadlineAugust 30 or when full

Fee: $190 per personMake check or money order payable to “AZDS.”

Submit Payment & FormMesa Parks and RecreationAttention: Jacquie GalloMS 7010 P.O. Box 1466Mesa, AZ 85211

Camp Carley 2019SEPTEMBER 19-21

Chandler Participant Mesa Participant

Participant: _____________________________________________________________ T-shirt size: __________________________

Address: ___________________________________________ City/State: ________________________ Zip code: ______________

Parent/Guardian: ___________________________________________ Parent’s e-mail:____________________________________

Phone (day): ________________________________________ (evening): _______________________________________________

Alternate person to contact in an emergency: ______________________________________________________________________

Relationship to participant: __________________________________ Phone number: ____________________________________

If for any reason, we should return early:

First contact person: ________________________________________ Phone Number: ____________________________________

INSURANCE INFORMATION

Insurance company: _________________________________________ Policy number: ____________________________________

Policy holder: ________________________________________________________________________________________________

Relationship to participant: _____________________________________________________________________________________

PLEASE TAKE THE TIME TO FILL OUT THIS SECTION THOROUGHLY

GENERAL PARTICIPANT INFORMATION

Behaviors:Does the participant have any unusual behaviors that staff needs to be aware of during the trip? No YesIf yes, please describe: ________________________________________________________________________

__________________________________________________________________________________________

Does the participant have a tendency to wander away from groups? No YesIf yes, can you give us any tips for managing these behaviors? ________________________________________

__________________________________________________________________________________________

Bedtime/Sleep Patterns:Will the participant have difficulty going to bed? No YesIf yes, please describe: ________________________________________________________________________

__________________________________________________________________________________________

Does participant have a history of wetting the bed? No Yes

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Participant: __________________________________________

MEDICAL INFORMATION

Participant’s physician: _____________________________________________ Phone: ____________________________________

Health History:Does participant have a history of frequent problems with any of the following?

________ Constipation ________ Asthma ________ Frequent urination

________ Allergies ________ Sore throat ________ Sinus problems

________ Hypertension ________ Dizziness/Fainting ________ Stomach discomfort

________ Heart Issues ________ Other: ___________________________________________________

Is participant on any medication? No Yes (If yes, please list below)

NAME OF MEDICATION DOSAGE TIME ADMINISTERED PRESCRIBING PHYSICIAN

For medication that needs to be administered daily, please bring medication in daily dosage envelopes provided on rally night.

Does participant have seizures? No Yes If yes, please explain the type and frequency: ____________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

In the event of a seizure, what follow-up should be given?: __________________________________________________

__________________________________________________________________________________________________

Does participant have any allergies? No Yes If yes: Food Medication Otherplease list: _________________________________________________________________________________________

__________________________________________________________________________________________________

Please continue to next page.

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Participant: __________________________________________

Diet:Are there any foods the participant is not allowed to eat? No YesIf yes, please describe: ________________________________________________________________________

__________________________________________________________________________________________

Should the participant be limited in the amount he/she eats? No YesIf yes, please describe: ________________________________________________________________________

__________________________________________________________________________________________

Fears/Dislikes:Are there any fears or dislikes the participant has? No YesIf yes, please describe: ________________________________________________________________________

__________________________________________________________________________________________

Female only: Will the female participant be on her menstrual cycle? No YesHow much assistance will she require? None Reminders Note: Camp Carley Staff are only able to provide minimal assistance with all self help needs.

Self Help Skills:Please mark any assistance participant may need (if any): ________ Eating ________ Shaving ________ Dressing

________ Brushing teeth ________ Combing hair

________ Other: ___________________________________________________________________

Special Interest/Hobbies:Are there any special interests, hobbies, recreational activities this participant enjoys? Please describe: ___________

__________________________________________________________________________________________

__________________________________________________________________________________________

Miscellaneous:Is there any other information that would be helpful for staff to know about the participant? __________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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Participant: __________________________________________

Camp Carley 2019SEPTEMBER 19-21

Over-the-Counter Medication Release Form

I give permission to administer the following over-the-counter medications as prescribed on the bottle.

Please check each one that applies: Tylenol tablets or generic equivalent Tylenol liquid (Adult Extra Strength) Ibuprofen / Motrin Advil Pepto Bismol – dosage on bottle varies for problem Tums Cough drops

Calamine lotion Benadryl Lotion Benadryl Tablets Other: ____________________________________ Other: ____________________________________ All of the above as listed on the label

Additional Comments: _______________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

HOLD HARMLESS AGREEMENT

This is my permission for ______________________________________________________________________to participate in the City of Chandler Therapeutic Recreation – “Off to the Mountains” Camp Carley Program. I hereby, for myself, my heirs, executors, administrators, and assigns, assume all risk and waive any and all claims for injuries and release the City of Chandler and the City of Mesa and their agents or assigns, from any and all injuries suffered by said person which may arise of or in connection with participation in these recreation programs. I authorize the City of Chandler and the City of Mesa staff to secure medical treatment, if necessary in the event of an emergency, and to dispense medication if required.

I also grant permission to the Recreation Division of Chandler or Recreation Division of Mesa to use the likeness, voice, words of the above in TV, newspaper, film/video, or other media, for the purpose of promoting the City of Chandler or City of Mesa Therapeutic Recreation Programs

I hereby, for myself, my heirs, executors, administrators, and assigns, assume all risk and waive any and all claims for damages caused to my personal electronic devices and release the City of Chandler and the City of Mesa, their agents or assigns, from responsibility for any and all damages caused to personal electronic devices carried on the “Off to the Mountains-Camp Carley” trip.

_________________________________________________ __________________________ Parent/Legal Guardian’s Signature or Participant (if over 18) Date

Please return the registration forms and the hold harmless agreement by Wednesday, August 30

Thank you!

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