Monett Summer Camp Application 2025 Participant Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Sex(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code School Attending(Required)*If homeschooled, please specifyTeacher, Grade, & Classroom Assignment(Required)Service Coordinator Name First Last Parent or Guardian Name(Required) First Last Parent or Guardian Address (If different from participant) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Enter Email Confirm Email Cell Phone(Required)Home PhoneWork PhonePrimary LanguageSecondary LanguagePrimary Diagnosis or DisabilitySecondary Diagnosis or DisabilityEmergency Contacts (Must list two)Emergency Contact #1(Required) First Last Cell Phone(Required)Home PhoneWork PhoneEmergency Contact #2(Required) First Last Cell Phone(Required)Home PhoneWork PhoneEmergency Contact #3 First Last Cell PhoneHome PhoneWork PhonePhysicianPrimary Physican(Required) First Last Phone(Required)Address Street Address Address Line 2 City Health HistoryMedication Taken?(Required) Yes No If you answered YES, the following MUST be completed. In case of a medical emergency, we need to know what medication(s) are taken, even if medication is NOT taken during recreation program hours.MedicationPlease list ALL medications including: name of medications, dosage, time to be given, and possible side effects.Ashma(Required) Yes No Does the individual require an inhaler?(Required) Yes No If answered YES to ashma, what is done to control/prevent an attack?Any Allergies?(Required) Yes No If answered YES to allergies, to what?Does the individual/you carry an EpiPen?(Required) Yes No If answered YES to an EpiPen, when should it be used? (Be Specific)Diabetic?(Required) Yes No If answered YES to diabetic, what shouldn't the individual eat/drink?Feeding Information Independent Needs some assistance Needs total assistance Pureed food Tube fed Other If other, please explain:Deaf/Hearing Impaired?(Required) Yes No Interpreter Needed? Yes No If answered YES to deaf/hearing impaired, how do you/the individual communicate?Nonverbal?(Required) Yes No If answered YES to nonverbal, can you/the individual communicate through different means?Physical Disability?(Required) Yes No If answered YES to physical disability, what is the disability?Wheelchair/Walker/Cane/Crutch?(Required) Yes No If YES, which type? Electric Wheelchair Manual Wheelchair Walker Cane/Crutch Physical Limitations?(Required) Yes No If answered YES to physical limitations, what are they?Safety Harness or Gait Belt Required?(Required) Yes No If answered YES to safety harness or gait belt, when is it utilized? Bus Classroom In the community Heart Condition?(Required) Yes No If answered YES to heart condition, what is it?Seizures?(Required) Yes No If answered YES to seizures, what happens before the seizures?If answered YES to seizures, what is the frequency of seizures?Date of Last Seizure MM slash DD slash YYYY Exposure to Sun?(Required) Full Minimum No Exposure Sunscreen may be used Swim Experience?(Required) Yes No Does the individual need a lifejacket?(Required) Yes No If answered YES to swim experience, what is the previous swim experience level & location?Toileting Information(Required) Toilet Trained Needs some assistance Needs total assistance Wears diapers If answered YES to needs some or total assistance, what assistance is needed?Are there any other health/medical concerns?What does the individual like?(Required)What does the individual dislike?(Required)Desired Outcomes and Expectations to be accomplished from No Limits Summer Camp (Be Specific)(Required)Any other information that would be of assistance in serving the individual?(Required)Parent/Guardian Signature(Required) First Last Date of Signature(Required) MM slash DD slash YYYY The Arc of the Ozarks Field Trip Permission Form(Required) I (parent/guardian) hereby give (participant) permission to go on all Field Trip outings with the Education/Recreation Department including, but not limited to the Continuing Education and Saturday Recreation programs. Participants in activities offered by The Arc of the Ozarks are not covered by medical or accident insurance. Each participant must furnish his/her own personal coverage. As a participant (or as a parent of an MR/DD participant), I release The Arc of the Ozarks board members, volunteers and employees from any liability to the participants for any personal injury or property damage suffered by the participants as a result of participation in the program. I assume all responsibility and agree to indemnify the sponsors and hold the sponsors harmless from and against any and all liability or cost arising from or in connection with the participant’s participation in the program. In case of accident or sickness, I consent to emergency medical care provided by the ambulance or hospital personnel.Parent/Guardian Signature(Required)Date(Required) MM slash DD slash YYYY The Arc of the Ozarks Swimming Permission Form(Required) I (parent/guardian) hereby give (participant) permission to go swimming. Participants in activities offered by The Arc of the Ozarks are not covered by medical or accident insurance. Each participant must furnish his/her own personal coverage. As a participant (or as a parent of an MR/DD participant), I release The Arc of the Ozarks board members, volunteers and employees from any liability to the participants for any personal injury or property damage suffered by the participants as a result of participation in the program. I assume all responsibility and agree to indemnify the sponsors and hold the sponsors harmless from and against any and all liability or cost arising from or in connection with the participant’s participation in the program. In case of accident or sickness, I consent to emergency medical care provided by the ambulance or hospital personnel.Parent/Guardian Signature(Required)Date(Required) MM slash DD slash YYYY The Arc of the Ozarks School Visit Permission Form(Required) I (parent/guardian) hereby give The Arc of the Ozarks permission to visit my child in regards to his/her participation in the programs offered by the Education/Recreation Department.Child's Name(Required)School Name(Required)*If homeschooled, please specifyGrade Level and Teacher(Required)Parent/Guardian Signature(Required)Date(Required) MM slash DD slash YYYY The Arc of the Ozarks Publicity Release(Required)I, (parent/guardian) hereby authorize The Arc of the Ozarks to include (participant’s) name and/or picture in the following (click all that apply): Select All Public materials (Magazines, newspapers, etc.) Promotional Materials (Websites, brochures, displays, etc.) Organizational Materials (Employee mailings, training media, etc.) I do NOT authorize The Arc of the Ozarks to to include (participant’s) name and/or picture in any materials. Parent/Guardian Signature(Required)Date(Required) MM slash DD slash YYYY
