Ontario Aphasia Retreat Day 2017 Application #: Application Form · 2017. 6. 28. · Ontario Aphasia Retreat Day 2017 Application #:____ Application Form Thank you for your interest

Ontario Aphasia Retreat Day 2017 Application #:____

Application Form

Thank you for your interest in Aphasia Retreat Day 2017! Date: Saturday, September 23, 2017 Time: 9:00 am – 5:30 pm Location: Woodeden Easter Seals Camp 2311 Oxford St W, London, ON N6K 4P1 Application: Every participant must fill out an application form. Submit by Monday July 31, 2017 to Alexis Dickson. Contact information at the end of this form.

PARTICIPANT INFORMATION

I am a person with Aphasia and I am accompanied by________________________

I am a person with Aphasia and I am attending alone

I am a friend/family member accompanying_______________________________

Have you attended Aphasia Camp before?

2008 2009 2010 2011 2012 2013 2014 2015(Retreat Day) 2015 (Full Camp) 2016 (Full Camp)

CONTACT INFORMATION

Last Name:

First Name:

Address:

City: Postal Code:

Telephone #: Email Address:

Date of Birth: Gender: female

woman

Emergency Contact Name:

Contact Person’s Phone #:

ACD 02-01x 07/17 2/11 Ontario Aphasia Retreat Day

HEALTH INFORMATION Please check all that apply.

stroke Seizures brain injury headaches

swallowing digestion diabetes

type 1 type 2

pregnant

vision

blood pressure

high low

angina

heart attack

heart disease wear glasses

chronic pain / arthritis

other joint concerns back pain hearing

wear hearing aid

asthma breathing problems incontinence bowel problems


Other:

What else do we need to know about your medical condition?

List your medications (or attach list).

I will need help managing my medications.


Allergies: yes no

trigger mild moderate severe

wheat

eggs

fish

dairy

peanuts

other nuts

shellfish

soy

Outside : trees, grass, etc.

Insects: bees, wasps etc..

other:

Do you use an EpiPen®? yes no


Special Diet: yes no

diabetic vegetarian vegan

gluten free low salt dairy free

pureed soft chopped pureed

thickened liquids ( nectar honey pudding)

no pork products

other: _________________________________________________

ACTIVITIES OF DAILY LIVING

NOTE: There will be attendants at the retreat day available for assistance.

Will you require attendant services during the day? yes no

Are you able to climb stairs safely without assistance? yes no

When going to the toilet, I use a:

raised toilet seat

commode

grab bars

left right catheter

none of these other: ______________________________


I need help with:

help

activity none some a lot

eating

toileting

showering or bathing

dressing


MOBILITY

Do you use an assistive device to move around? yes no

If yes, what device do you use?

How much help do you need?

help

device none some a lot

cane

walker

wheelchair

COMMUNICATION

I have difficulty with:

type none some a lot

understanding

talking

reading

writing


What helps you to communicate? Please circle.

writing

drawing

communication book

choices

iPad or device

camera

family or friend

extra time

gesture

pointing

pictures

maps

speak slowly boating key words

quiet

Other:

PAYMENT

Please enclose cheque or credit card information with this application.

All financial information is confidential and destroyed once payment is processed.

Application will only be processed when payment is received.

Cost: $45.00

Cheque

Make payable to: March of Dimes Canada


Credit Card:

Visa MasterCard American Express

IMPORTANT: We will call you for your credit card information upon your

acceptance to camp 2017.

Consent

The attendant services staff may help me with my medications.

yes no

If I have a medical emergency, my emergency contact will be phoned.

If they cannot be reached, 911 may be called.

yes no

Photographs, videos, and/or stories of me may be used by: yes no

March of Dimes Canada yes no

Signature of applicant:

Date:


It is important that we have all information.

The Aphasia Retreat Day Planning Committee will review all application so we can meet your medical needs to the best of our ability.

At this time we are unable to provide support for some medical conditions.

Send your application and payment to:

Alexis Dickson March of Dimes Canada 10 Overlea Blvd Toronto, Ontario M4H 1A4 Email : [email protected] Phone : 1 800 263 3463 x 7756

Please note that submitting an application does NOT guarantee acceptance.

Applicants will be notified by mail by late August of their acceptance status.

We will not charge you if you are not accepted.


Registration is at 9:00 am. Pick up at 5:30 pm.

People with aphasia, please help us with our planning by indicating your first and second choice for each time slot. Please note that your first choice is not

guaranteed. However, we will do our best to accommodate everyone. Friends and family we have exciting plans for you too- please see below the adapted

activities for your schedule!

This is a tenative schedule subject to change.

10:45-11:45 am

1:15- 2:15 pm

3:00-4:00 pm

Caregivers/Friends/Family

10:45-11:45am: Yoga 1:15-2:15pm: Painting art activity

3:00-4:00pm: Networking session on the importance of leisure/stress management and self-care

We look forward to a day away with you!

adapted floor hockey

adapted archery

adapted yoga adapted archery

adapted archery nature candles craft

Documents

Ontario Aphasia Retreat Day 2017 Application #: Application Form · 2017. 6. 28. · Ontario Aphasia Retreat Day 2017 Application #:____ Application Form Thank you for your interest