South East Consortium Summer Day Camp Programs

Thank you for your interest in the South East Consortium Summer Day Camp Programs. I am delighted

to share with you the following information which provides a basic understanding of these unique and

highly respected inclusive summer day camp programs.

Once again, this year we will be offering SEC Summer Day Camps in the Town of Eastchester and Village

of Scarsdale. Based on the fact the highest percentage of campers comprising enrollment in 6th, 7th & 8th

grades reside in Eastchester, Bronxville and Tuckahoe, South East is partnering with the Town of

Eastchester Department of Recreation to enroll summer campers in the aforementioned grades in the

Eastchester Camp Galaxy which is located at Greenvale School. This will solve the overcrowding in

Scarsdale and will offer our Eastchester, Bronxville and Tuckahoe campers the opportunity to attend

camp in their own town.

If you decide your child meets our eligibility requirements and you wish to pursue enrollment, please

complete the enrollment packet and forward with payment as stated below. If you are new to South

East, you will be required to make an appointment with your child for a brief in-take appointment to

assess your child’s preparedness for camp and to finalize enrollment. If it’s decided your child will be

enrolling for camp, more comprehensive information will be provided. Please read the following

carefully, as the structure of camp has changed to accommodate the program’s growth.

Orientation Meeting for Families: An orientation meeting for families will be held on Wednesday, June

13th at the Mamaroneck Town Center, South East Consortium Office, Suite 316 from 6:30-8:00PM. It is

highly recommended all families attend. It is mandatory for any new families to attend.

Camp Dates: June 26th – August 3rd for SEC Eastchester Day Camp (28 days) between the hours of

9:00AM – 3:00PM. No Camp on Wednesday, July 4th in observance of Independence Day.

Camp Location and Age/Grade Levels: The Town of Eastchester will be hosting camp for 6th – 8th

graders at Camp Galaxy who reside within Eastchester, Tuckahoe and Bronxville. All campers enrolled

with South East are interactively grouped with municipal campers as appropriate. South East campers

are supervised by South East staff who will be accountable to a South East Camp Director at each camp

location.

Camp Galaxy (6th-8th Grades): Greenvale School, 1 Gabriel Rescigno Drive (next to Haindl Field) for

Campers residing in Eastchester, Tuckahoe and Bronxville.

Camper Eligibility: Any child, age 5-14 who is diagnosed with a Developmental Disability (ask for a

definition) who resides in one of the component municipalities and is confirmed OPWDD eligible for

reimbursement under the New York State Office for People with Developmental Disabilities Office

guidelines will be given priority. Children with other special needs or those who do not qualify for

OPWDD Eligibility are encouraged to seek enrollment but will need to pay an additional fee.

However, it must be understood that South East, due to staffing limitations, cannot accept any child

requiring specialized health care or supervision which exceeds the ability of South East to properly

accommodate. Also, South East cannot accept for enrollment children who present severe behavioral

challenges and are deemed inappropriate for such a camp environment.

Camp Cost: Confirmed OPWDD Eligible/HCB Medicaid Wavier $425.00

Non-OPWDD Eligible/Other $925.00

The average cost incurred by South East for your child to attend summer camp is approximately $1,850.00. Interpretation of Medicaid Waiver regulations permits SEC to assess families a cost of $425.00 based on allowable expenses. Campers who are Non-OPWDD Eligible/Other are assed a fee of $925.00. Enrollment: Enrollment is open to members of the consortium through May 18, 2018. If space is

available enrollment will be open to members outside the consortium after 5/18/18. Please note we

have a limited number of spots available at each camp site this year. 6th – 8th grade camp site enrollment

is determined by the municipality to which you pay your taxes, not by school district or mailing address.

Please fill out the corresponding forms for the camp your will be attending.

Payment: Full payment for camp would be appreciated at the time of enrollment/acceptance. A

payment plan for camp requires $100 deposit due at the time of enrollment/acceptance and the second

payment by May 7th, and the final payment on June 18th. Full payment must be received by June 18th for

your child to attend camp.

Camp Staff: South East employs a seasoned, experienced professional as Camp Director at each camp

site. South East provides counselor staff at a 1:2 ratio to supervise campers at all times. If it is mutually

agreed your camper requires 1:1 supervision, then we will discuss with you available options. Camp

counselors range from teacher aides, to college and high school students. All staff realize their primary

function is to provide productive, enjoyable camp activities for campers in a respectful and safe manner.

South East shares the services of an EMT personnel for health purposes. Each staff must undergo a

criminal background check and fingerprint screening. All staff attend a three-day orientation session

prior to the start of camp.

South East Consortium for Special Services, Inc

740 W. Boston Post Road, Ste 316

Mamaroneck, NY 10543

Telephone: (914) 698-5232

www.secrec.org

South East Consortium

Camp Galaxy at Eastchester Enrollment Form 2018

It is imperative that all requested information below is provided. There will be no exceptions. Failure to provide the requested

information may result in your child not being accepted. Each camper must have a current South East Admission Application and SEC

Medical form on file (which is valid for 3 years). In addition, updated immunization record needs to be attached to this enrollment

form. *Note:6th – 8th grade camp site registration is determined by the municipality to which you pay your taxes, not by school district

or mailing address.

Name of Camper: _____________________________________________________________________________

Address: ____________________________________________________________________________________

Municipality you pay taxes to: ___________________________________________________________________

Camper Information:

Date of Birth: __/___/_____ SS # mandatory: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Gender: ____________

Primary Diagnosis: _________________________________Secondary Diagnosis: _________________________

Is your child on Medicaid Waiver? _________________ If so, what is the CIN ? ___________________________

Parent/Guardian: _______________________________________________________________________________

Home Phone: ________________________________ Cell Phone: ________________________________________

Email Address: ________________________________ Emergency Contact: _______________________________

My Camper will be attending ALL 6 weeks of camp.

My Camper will be away from camp on _________________________

What Camp Are You Requesting?

FOR OFFICE USE ONLY

Date Registration Received: _______________ Date Medical Received _____________Payment made by: _________/____________

Date(s) Payment(s) Received: __________/___________ Check(s) #: ________ / _________ Amount(s): __________/ __________

JSK DP MB Medical Immunization Records IEP Application Sunscreen Swim

Camp Galaxy (6th – 8th Grade) Code: GALA 310

Summer Camp Confirmed OPWDD Eligible/HCB Medicaid Wavier $425.00

Summer Camp Non-OPWDD Eligible/and other $925.00

A minimum Deposit of $100.00 is due with enrollment form to hold a spot for your camper. DEPOSIT$ __________TOTAL$____________

Payment for camp must be made by June 18th, 2018.

PAYMENT PLAN: Payment plan for camp requires a deposit of $100 due with application, seconded payment by May 7th and final

payment on June 18th.

If you agree to the term of this agreement, please sign and date.

Signature__________________________________________________________________Date__________________________

Program Admission Application 02/2013

South East Consortium for Special Services, Inc.

740 West Boston Post Road, Suite 316 | Mamaroneck, NY 10543

Program Admission Application

Please complete this application accurately and completely to ensure safety and program effectiveness

This application is valid for three years

Name of Participant: __________________________________________________________ DOB: _____/____/______ Sex: M F (circle one)

Participant’s Social Security # (required): _________________________ Participant’s Medicaid Waiver # (if applicable): ____________________

Parent/Guardian’s Name: _________________________________________________________________________________________________

Address: _______________________________________________________, ________________________________, _______, ______________

Street Municipality State Zip Code

Home Phone: _____________________________ Cell Phone: _______________________________ Email: _______________________________

Emergency Contacts: (if parent(s)/guardian(s) are unavailable:

Primary Person: _____________________________________________________ Best Phone #: _______________________________________

Secondary Person: __________________________________________________ Best Phone #: _______________________________________

Relationship to Participant: Primary_____________________________________ Secondary _________________________________________

Parent/Guardian’s Release Statement

I am the parent/guardian of _____________________________________________ (Participant) on whose behalf I have submitted this

Admission Application for his/her participation in the programs and activities of the South East Consortium (SEC). I represent and warrant that,

to the best of my knowledge and belief, the Participant is physically and mentally able to participate in SEC’s programs and activities.

The SEC has my permission to use (both during and after a program or activity) the likeness, name, voice or words of the Participant in television,

radio, film, newspaper, magazine and other media or formats, for the purpose of advertising or communicating about the SEC’s programs and

activities and/or for the purpose of applying for or raising funds to support these programs and activities.

I hereby release and discharge the SEC, and its officers, directors, employees, supervisors and volunteers from any and all claims for damage,

personal injury and other liability in connection with events occurring while the Participant is involved in the SEC’s programs and activities.

If, during the Participant’s involvement in the SEC’s programs and activities, he/she were to need emergency medical treatment, I hereby

authorize the SEC to take such measures as it may deem necessary for the benefit of the Participant’s health and well-being (including, if

necessary, hospitalization).

Do you carry health/medical insurance for the Participant? Yes No. If “No” – I will be responsible for payment of all medical services rendered.

Name of Insurance Company: ____________________________________________________ Policy #: _______________________________

_____________________________________________________________________________________________________________________

Release of Test Score Information Required by New York State OPWDD

In order to ensure the Participant’s eligibility to receive the important funding which is provided to the SEC by the New York State

Office for People with Developmental Disabilities (OPWDD), the SEC is required to provide to said Office the individual I.Q. scores,

Vineland Adaptive Behavior Scale Scores or other recognized assessment instruments in connection with the Participant. By submitting

this application to SEC, you are confirming that the SEC may release this required information to the New York State OPWDD. Your cooperation is

appreciated.

Program Admission Application 02/2013

Delivery of the Participant

The South East Consortium may release the Participant only to the persons named below:

Name: ____________________________________________________________ Relationship: ________________________________

Name: ____________________________________________________________ Relationship: ________________________________

I give my permission for the Participant to arrive and depart the SEC’s programs on his/her own. Y N . Circle one

Signature: _________________________________________________________ Date: ______________________________________

Parent/Guardian and also by the Participant (if 18 years or older). Must be signed to participate.

Participant Information

Participant’s School or Workplace: ________________________________________________________________________________________

Brief description of family and living situation: ______________________________________________________________________________

____________________________________________________________________________________________________________________

What does the Participant enjoy during free time? ___________________________________________________________________________

____________________________________________________________________________________________________________________

What outcomes would you like the Participant to achieve? ____________________________________________________________________

____________________________________________________________________________________________________________________

Daily Living Activities Comments___________________________________________

Assistance eating/drinking Yes No________________________________________________________________________

Assistance with toileting Yes No ____________________________________________________________

Assistance with dressing Yes No________________________________________________________________________

Other thinks we should know____________________________________________________________________________________________

Social Ability_________________________________________________________________________________________________________

Interacts with others Yes No________________________________________________________________________

Unusual fears or concerns Yes No________________________________________________________________________

Aggressive behavior/outbursts Yes No________________________________________________________________________

Leaves or wanders from groups Yes No________________________________________________________________________

Other things we should know Yes No________________________________________________________________________

Cognitive/Communication Ability________________________________________________________________________________________

Verbal/Non-verbal Yes No________________________________________________________________________

Hearing speech/hearing impairments Yes No________________________________________________________________________

Other things we should know____________________________________________________________________________________________

Physical Ability_______________________________________________________________________________________________________

Ambulatory Yes No________________________________________________________________________

Gross/fine motor ability Yes ______________________________________________________________________________

No_____________________________________________________________________________________________________________

Over/under active Yes No________________________________________________________________________

Likes physical activity Yes No________________________________________________________________________

Other things we should know

Update 2/28/2006

MEDICAL INFORMATION This medical will be valid for three years from the date issued by the physician.

THIS SECTION IS TO BE COMPLETED BY A PHYSICIAN ONLY!!

Please return to: South East Consortium PARENT/GUARDIAN IS 740 W. Boston Post Road, Suite 301 RESPONSIBLE FOR UPDATING Mamaroneck, New York 10543 MEDICAL INFORMATION ON A Telephone (914) 698-5232 REGULAR BASIS. Participants cannot attend programs Fax (914) 698-7125 without an updated medical.

Name:__________________________________, _______________________________________, ________________________________________ Last Name First Name Middle Name

Primary Diagnosis:____________________________________ Secondary Diagnosis:_____________________________________________

Down Syndrome Yes No Atlanto-Axial Instability by X-Ray Evaluation Results Date:________ Positive Negative No X-Ray Given

HISTORY OF… (include comments at right for “YES” responses)

CHECK ONE COMMENTS/OTHER RESTRICTIONS

Allergies (Food, Bee Stings, Etc.) Yes No Anxiety Yes No Asthma Yes No Bladder/Kidney Problems or Loss of Function in one Kidney

Yes No

Bleeding Problem Yes No Bone or Joint Problem Yes No Bruising Yes No Circulatory Problems Yes No Contact Lens/Glasses Yes No Depression Yes No Diabetes Yes No Emotional Problems Yes No Fainting Spells Yes No Head Injury/History of Concussion Yes No Hearing Aid/Hearing Problems Yes No Heart Problems Yes No Blood Pressure ___________/_________ Heart Illness Yes No Hernia or Absence of one Testicle Yes No Hepatitis TYPE:____________ Yes No Hypoglycemia or Hyperglycemia Yes No Motor impairment Requiring Special Equip. (i.e., Wheelchair, Orthopedic Device)

Yes No

Recent Contagious Disease Yes No Seizures: Date of Onset: _____/_____/_____ Yes No Frequency: Duration: Type: Yes No Time of Day: Special Diet Needs Yes No Vision Problems and/or vision less than 20/200 in One or Both Eyes

Yes No

Other Yes No

HISTORY OF DISEASE(S): DATE OF ONSET: Chicken Pox Yes No Mumps Yes No Measles Yes No Pneumonia Yes No German Measles Yes No Rheumatic Fever Yes No Tuberculosis Yes No

Update 2/28/2006

MEDICAL HISTORY

IMMUNIZATION RECORD (Required By NY State Law) Any participant born before 1/1/57 does not have to complete the immunization record # 3 – 6 Diptheria/Tetnus Toxoid (4 doses) dates: (must be boostered every 10 years)

1) 2) 3) 4)

Hepatitis B Vaccine (3 doses): 1) 2) 3) 4) Oral PolioVaccine (3 or more doses) dates: 1) 2) 3) 4) Live Measles Vaccine (2 doses) dates: 1) 2) 3) 4) Live Rubella Vaccine (1 doses) date: 1) 2) 3) 4) Live Mumps Vaccine (1 dose) date: Haempphilus Influenza type B (Hib) (1 dose) date: Varicella (chicken pox) (1 dose) date: Give Dates: _________________ Results of: TUBERCULIN TEST_______________________ _________________ CHEST X-RAY:____________________________ _________________ TETANUS:________________________________ MEDICATION INFORMATION: MUST BE FILLED OUT COMPLETELY, EVEN IF PARTICIPANT DOES NOT TAKE MEDICATION AT PROGRAMS. (Please Initial in the box provided if adult (age 18 or over) participant may self-administer medication during program hours). Please contact SEC office for medication self-administration form.

Initial Medication Purpose Dosage Frequency Time ALLERGIES TO MEDICATION: YES NO If yes, What?______________________________________________ ______________________________________________ If there is a change in any of this information, a new form must be completed.

MEDICAL RELEASE

South East Consortium provides community-based recreation for individuals with disabilities, with an emphasis on physical activities. If you feel any particular activity is contra-indicated for this individual, PLEASE CHECK ONLY THOSE ACTIVITIES IN WHICH THE PARTICIPANT MAY NOT PARTICIPATE.

Alpine Skiing Diving Golf Soccer Track & Field Basketball Equestrian Gymnastics Softball Volleyball Bowling Figure Skating Motor Activities Strength Training Other Cycling Fitness/Aerobics Nordic Skiing Swimming Dance Floor Hockey Roller Skating Tennis

I, the undersigned have reviewed the above medical history and certify there is no medical evidence available to me which would preclude his/her participation in South East Consortium for Special Services Recreation Programs. Doctor’s Name: (Printed)_________________________________________________________________________________ Doctor’s Signature (must be signed in ink)____________________________________________________________________ Address:________________________________________________________________________________________________ ___________________________________________________________________________________________Zip:_________ Telephone: ( )__________________________________________________________Date:_____________________ Fax:: ( )____________________________________ E-Mail:_____________________________________________

South East ConsortiumCamp Galaxy

Swim Permission Slip

The New York State Department of Health requires all camps to have written permission for children to participate in any o� site camp activities such as swimming at the Lake Isle pool complex.

Please complete the form below and return it to the South East Consortium by June 18, 2018. Children with signed permission slips will only be allowed to participate in the aforementioned activities. If you have more than one child participating in camp, please �ll out one form per child. Thank you for your assistance.

South East Consor�um Day Camp Off-Site Ac�vityPermission Slip Camp Galaxy

I give my child _______________________entering Grade (in September) __________ , permission to par�cipate in the Eastchester Camp Galaxy Off-Site Ac�vity Program conducted at the Lake Isle Pool Complex throughout the summer of 2018. I understand the following:

• Campers will be transported to the off-site facili�es by school bus.• Campers will be supervised by camp staff as well as qualified lifeguards at the swim facility.• Campers will be iden�fied by their swim ability with a colored wristband.

Parent/Guardian Name: __________________________________________________Signature of Parent/Guardian: _____________________________________________

Please return by June 18, 2018 to:

South East Consor�um For Special Services Inc.740 West Boston Post Road, Suite 316

Mamaroneck, New York 10543Fax number (914) 698-7125

South East ConsortiumCamp Galaxy

Sunscreen Authorization form

Camper’s name _____________________________________________

Please complete and sign this form if you would like your chi ld/teen to use, carry and/or would like assistance applying sunscreen during camp hours.

Chapter 242 amended NYS Public Health Law permitting a child to possess and use sunscreen at camp when all the following apply:(1) It is used to protect against overexposure to the sun.(2) It is approved by the FDA for over-the-counter use (3) The parent or guardian provides written permission for the child to carry

Sunscreen Permission:

□ I consent to have my camper carry and use sunscreen she/he has brought to camp, which is FDA approved for over-the- counter use to avoid overexposure to the sun.

Parent/Guardian Signature: ____________________________________

Print Name: __________________________________ Date: ____/___/___ □ I consent to have a day camp staff member assist with the applica�on of sunscreen when my child is unable to do so, or if my child requests the assistance.

Parent/Guardian Signature: ____________________________________

Print Name: __________________________________ Date: ____/___/___

South East ConsortiumCamp Galaxy

Medication Authorization

Camper’s name _____________________________________________ Grade in Sept. __________

Address ___________________________________________________________________________Parents’ names _____________________________________________________________________Mother’s cell (_____) _____-________ Home (_____) _____-________Work (_____) _____-________ Father’s cell (_____) _____-________ Home (_____) _____-________Work (_____) _____-_________ Emergency Contact Person _________________________________ Phone (_____) _____-_________ Check all that apply:□ I would like my child/teen to carry their EpiPen/Benadryl/inhaler (circle one) at all times.□ I would like my child/teen’s EpiPen/Benadryl/inhaler (circle one) to be stored in the camp office.□ I would like my child/teen’s EpiPen/Benadryl/inhaler (circle one) to be stored in the pool office. Parent/Guardian Signature: ____________________________________

I hereby grant permission to the camp EMT and administrative staff to store and to supervise the self-administration of my child/teen’s medication as detailed below by our physician.

In accordance with the Nurse Practice Act and the State Education Law, camp personnel may not dispense medication - whether prescribed or over-the-counter - to a cmaper unless it is authorized by the camper’s parents and their physician.

This form allows the camp EMT and administrative staff to store your child’s medication and to supervise your child in self-administration of their own medication. Please complete a separate form for each individual medication and submit it with your child’s medication in it’s orginial container to the camp office. Note: Emergency medication (e.g. EpiPen, Benadryl, albuterol inhaler) may be carried by your child instead of being stored in the camp office.

Date: ____/___/___

This portion must be completed by your child/teen’s physician. Date____/____/___________________________________is to receive __________________________________ child/teen name medication

for ________________________________________________________________________ indicationDose_____________________Route____________□ PRN or □ Frequency ________________Notes: ______________________________________________________________________Physician’s Name ____________________________ Signature ________________________Phone (_____) _____-_________ Address________________________________________________