CAMP SPARKSThe Arc of Tippecanoe County’s Camp SPARKS is a summer day camp for all children ages 5-17. Camp SPARKS provides an inclusive camp experience. Children with disabilities are accommodated and supported in the camp environment and participate alongside their non-disabled peers and siblings. At camp SPARKS children socialize, have fun, learn and play. Campers have fun in an environment that promotes social skills, independence, builds self-esteem and creates friendships. Camp SPARKS and the Arc of Tippecanoe County strive to promote a positive image of people with disabilities in our community.

Dates: June 27nd - July 22nd, 2016 (Weekdays) (No Camp on July 4th)Time: 1:00pm – 5:00pmPlace: Linwood Elementary 1415 Ball St., Lafayette, IN 47904Cost: $350 per camper Early bird Discount: $300 (Must receive application & payment by May 1st, 2016 to receive discount)Parent’s camp orientation open house: Wednesday, June 22, 2016 5-7pm To register, please complete the attached application forms and return them by May 23, 2016. You may mail or email the application. The fee can be paid by check and mailed or using PayPal on the Arc of Tippecanoe website. There is a $25 returned check fee. Camp fees must be paid in full by the first day of camp. Space is limited & camp is filled as registrations are received. Registration is complete only when the registration forms, physician’s release and camp fee are received.

Mailing a check for payment: payable to: The Arc of Tippecanoe County

Using PayPal for payment: http://www.arcoftippecanoe.org/wp/?page_id=20 (click on donate)

Emailing Application: campsparks@arcoftippecanoe.org Subject line should include child’s last name and SPARKS

Mailing Application: Camp SPARKS

The Arc of Tippecanoe CountyP.O. Box 1222

Lafayette, IN 47902-1222

Questions? Call the Arc office at 765-476-3277 or email at campsparks@arcoftippecanoe.orgCamp SPARKS does not provide transportation or one-on-one assistance. If you believe that your child requires one-on-one assistance, please arrange for a provider to be with your child.Page 1 of 12

PO Box 1222Lafayette, IN 47902-1222765-476-3277www.arcoftippecanoe.org

campsparks@arcoftippecanoe.orgwww.arcoftippecanoe.org/

Camp SPARKS Scholarships, Discounts and Referrals

There are a limited number of scholarships for which families may apply. Scholarships may or may not be available based on availability of funds.  If you would like to be considered for a scholarship check the appropriate box below. Scholarship awards will be made at the beginning of June if funding allows. Families will be notified.

Child’s Name: __________________________________________

Parent Name: ____________________________________ Phone: _____________________

I would like to apply for a scholarship based upon my family size and household income. Scholarship awards will be made at the beginning of June if funding allows. Families will be notified.

*To be considered for this scholarship, please provide proof of 2015 gross household income.

I would like to apply for a scholarship based upon the number of children I will be sending to Camp SPARKS this summer. We strongly encourage siblings of children with special needs to also attend camp! We offer a 10% discount for each additional sibling. Must receive application & payment by May 1st, 2016 to receive the early bird discount.Total number of children in your family you are registering for camp: ______First Child $350, early bird discount $300Second Child $315, early bird discount $270Third Child $280, early bird discount $240Fourth Child $245, early bird discount $210I would like to apply for an Arc employee discount. Camp fees must be paid in full by the first day of camp. Camp director will inform employees of the fee rate.

Arc Employee Name: __________________________________________

Children’s Names __________________________________________

__________________________________________

Camp SPARKS is offering an incentive for camp referrals. If you are coming to camp for the first time because of the recommendation of past camper please provide their name.

Page 2 of 12

_________________________________

Camp SPARKS Parent Permission

I give my permission for my child to participate in The Arc of Tippecanoe County’s Camp SPARKS program, including swimming and field trips. I will not hold The Arc of Tippecanoe County or any of its employees or volunteers liable for any injuries that may occur during participation in the camp or in transit to and from an activity.

Parent/Guardian Name:__________________________________________

Signature of Parent/Guardian: _______________________________Date: __________

Camp SPARKS Photo Release

This is to indicate that I (please circle) do / do not grant permission for any photographs to be taken of my child while participating in activities connected with Camp SPARKS that will be used for any purpose by The Arc of Tippecanoe County. Photos may be taken at times for newspapers, television, brochures, social media, the Arc website or professional publication.

Parent/Guardian Name:__________________________________________

Signature of Parent/Guardian: _______________________________Date: __________

Camp SPARKS Parent Authorization for Emergency Medical Treatment

Camp SPARKS Medical Authorization for Treatment of a Minor (persons under 18 years). Pursuant to Indiana Code Paragraph 16-36-1-6, I request and authorize Camp SPARKS STAFF, medical personnel, agents, and employees to provide all reasonably necessary medical care advisable for the health of my child, including but not limited to medical transport, hospital tests, such as pathology, radiology, anesthesia, evaluation and treatment by physicians, including surgery, and prescription drugs. I acknowledge that no representations, warranties, or guarantees can be made with respect to any medical care or treatment provided. I also understand that, as a result of my child’s participation in this program, it will be necessary for supervisors and others involved with the program to have access to relevant medical information pertaining to my child, and I authorize the use and disclosure of my child’s medical information to promote a safe and healthy experience for my child.

Further, I hereby grant permission for my child(ren):

____________________________________________________________________________________To attend the Camp SPARKS Program by signing below. A signature from one or both parents/legal guardians and a witness signature are required.

Signature Parent/Legal Guardian (required)

____________________________________________________Date_________Signature Parent/Legal Guardian/Witness (required)

____________________________________________________Date_________

Page 3 of 12

Camp SPARKS Physicians Release Date of exam: ____________________________________

A physical examination form must be completed by a physician each year prior to camp.

Camper’s full name: Date of Birth:

Address: Gender:

City: State: Zip:

Parent/Guardian Name: Home Phone: Work Phone:

Address (if different than camper): __________________________________________

Emergency Contact (other than parent): ________________ Home Phone: _________

Health/Accident Company: Policy Number: Medical Information

1. Heart Disease/Heart Defect/ Y NHigh Blood Pressure

2. Chest Pain or Fainting Spells3. Seizures/Epilepsy4. Diabetes5. Down Syndrome6. Absence of vision/blind in one eye7. concussion or serious injury8. Major surgery or serious illness9. Heat Stroke/exhaustion10. Other problems that would interfere

with camp participationList:

11. Impaired motor ability12. Uses a wheelchair

13. Allergy to the following Y N(list specific)

14. Exercise induced wheezing15. Tendency to bleed easily16. Special Diet17. Emotional/psychiatric/behavior

Problems18. Serious bone or joint disorder19. Hearing aid/hearing loss20. immunizations (shots) are

up-to-date

Comments: MEDICATIONS-Please print medication name, amount, date prescribed and number of times per day medication needs to be taken. MEDICAL CERTIFICATION

I have reviewed the above health information on and examined the camper named in the application, and certify there is no medical evidence available to me, which would preclude the camper’s participation in CAMP SPARKSRestrictions

Examiner’s Signature (MUST be a physician)

Examiner’s Name Phone

Address Date

Page 4 of 12

Camp SPARKS Registration Please complete for each child attending Camp SPARKS

Child’s Name: __________________________________________ Phone: ________________

Child’s Address: ________________________________________________________________

Gender: Female Male Age: _______ Birthday: _____-____ -____

School _________________________________________ Grade Completing ____________

Primary teacher: __________________________________ School Corporation: LSC TSC WLSC Other

T-shirt size (circle one): Child Small Child Medium Child Large

Adult Small Adult Medium Adult Large Adult X-large Adult XX-large

Child lives with: _____________________________________________________________ Parent Name: ____________________________________ Phone: _____________________

Parent Name: ____________________________________ Phone: _____________________

Parent Name: ____________________________________ Phone: _____________________

Parent Name: ____________________________________ Phone: _____________________

Sibling Name: _____________________________________ Attending Camp? _________________

Sibling Name: _____________________________________ Attending Camp? _________________

Sibling Name: _____________________________________ Attending Camp? _________________

Sibling Name: _____________________________________ Attending Camp? _________________

Email Address to receive camp information: _____________________________________________Would you like a free membership to The Arc of Tippecanoe County to learn about upcoming events and other information relevant to people with intellectual/developmental disabilities? yes no

Emergency Contacts (used if neither Parent/Guardian listed above can be reached):

Name & Relationship to Camper & phone #: ____________________________________________

Name & Relationship to Camper & phone #: ____________________________________________

Does your child wear or need any special equipment? (hearing aids, braces, wheelchair, etc.) Please describe:

__________________________________________________________________________________________Page 5 of 12

Race:

African American American Indian Asian/Pacific Islander Caucasian Hispanic/Latino/Chicano Multi-Racial Other Ethnic Designation ____________________

Current Household Income Level: Under $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999

$50,000-$74,999 $75,000-$99,999 $100,000+

Does your child qualify for free or reduced lunches at school: Reduced Lunches Free Lunches No

Is your child’s primary language something other than English? If so, describe:

____________________________________________________________________________________

Please List Current Medications: ** If camp staff is to administer medications, your child’s physician will need to list them on the physician form with their name and the dosage to be administered. The medication must be supplied in a pharmacy bottle and given to the Camp Director.

_________________________________________________________________________________

_________________________________________________________________________________

Does your child have any allergies? Yes No If yes, please list allergen below with possible reactions:

_________________________________________________________________________________

Special Diet: ______________________________________________________________________

Does your child have any sensory, physical or other medical restrictions/considerations: Please describe:

__________________________________________________________________________________________

__________________________________________________________________________________________

Does your child enjoy swimming? ____yes ____no please describe your child’s swimming abilities:

__________________________________________________________________________________________

__________________________________________________________________________________________

Does your child have any special hobbies or interest? What does your child enjoy doing?

__________________________________________________________________________________________

__________________________________________________________________________________________

Can your child participate in vigorous outdoor or indoor games/sports? Yes No

Page 6 of 12

If no, can you please specify limitations on activities or any activities that must be avoided?

__________________________________________________________________________________________

__________________________________________________________________________________________

Are there any campers that your child enjoys being with? _____________________________________

Are there any campers that your child does not get along with? _____________________________________

Is there anything else you wish to tell us about your child that would help camp staff? (Behaviors, activities, and

treats they enjoy, motivating items, things staff should watch for etc.). Please feel free to give as much detailed

information as you feel is appropriate. Thank you for your help in making Camp SPARKS a fun experience for

your child!!

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please select 2-3 goals you would like to see your child work on at camp this year.

I want my child to socialize with peers.

I want my child to trying new things.

I want my child to follow rules and learn about sharing of communal responsibilities.

I want my child to participate with a group of peers.

I want my child to work on better handling change.

I want my child to be able to adapt to new situations and meet and interact with new people.

I want my child to know how to build friendships to have a social support network.

I want my child to become more independent and resilient.

I want my child to make friends and develop stronger social skills.

I want my child to focus on talking and relating to other campers.

I want my child to learn from positive adult and peer role models.

I want my child to acquire new athletic, artistic and outdoor living skills.

I want my child to focus on having fun!

I want my child to recognize acceptable behavior across different community settings

I want my child to work on making eye contact and recognizing personal space

Other:

Page 7 of 12

Camp SPARKS Pick-up PeopleFor the safety and security of your child/ren, we at Camp SPARKS would like a list of eligible “Pick-up People”. A “pick-up person” is a person/s that you authorize to pick up your child/ren from the program each afternoon. We would like to ensure all your children’s safety and security by creating an authorized list of people that you (parents/guardians) designate as the only people allowed to pick up your child/ren from Camp SPARKS.

THIS FORM ONLY NEEDS TO BE COMPLETED IF THE PARENTS/GUARDIANS WHO COMPLETED THIS REGISTRATION PACKET ARE NOT GOING TO BE PICKING UP THE CHILD/REN.

We will ask for your special code word and may request identification from EVERYONE (including parents/guardians) who picks up a child each afternoon, so please inform anyone who may be picking up your child/ren that they will need photo identification and/or the code word (and so will you!). If you have any questions, please contact the Arc office at campsparks@arcoftippecanoe.org or 765-476-3277.

Please provide a copy of the driver’s license for all those people that will be authorized to pick up your child with this application

Child/ren’s Name/s: ________________________________________________________________

Code word: _______________________________________________________

Pick up Person #1: ________________________________________________________________

Relationship to child: ________________________________________________________________

Telephone #: ________________________________________________________________

Drivers’ License #: ________________________________________________________________

Pick up Person #2: ________________________________________________________________

Relationship to child: ________________________________________________________________

Telephone #__________________________________________________________________

Drivers’ Licensee # ___________________________________________________

Page 8 of 12

Complete this portion of the application only if your child has a disability.

Please provide a copy of your child’s IEP with your registration. For each student providing an Individual Education Program (IEP) that participates in Camp SPARKS, all portions of the IEP will remain confidential. Camp SPARKS’ staff will use the information provided to better serve your child and the IEP will be destroyed at the end of camp.

May we contact your child’s teacher? Yes No

Did your child have a one-on-one aide during the school year? Yes No

List the disabilities on your child’s IEP or as diagnosed by the doctor (check ALL that apply):

Autism Spectrum Disorder Language/Speech Impairment Blind/Low Vision

Emotional Disability Deaf/Hard of Hearing Specific Learning Disability

Cognitive Disability Multiple Disabilities Orthopedic Impairment

Other Health Impairment Deaf-Blind Traumatic Brain Injury

Does your child have a medical diagnosis for their disability or condition(s)? If so, please describe.

__________________________________________________________________________________________

If you answer YES to any question below, please explain.

Does your child need one-on-one support? Please describe any staff you are

providing.

YES NO

Does your child need one-on-one support to swim? YES NO

Does your child need help getting dressed and undressed for swimming? Does your

child require a swim diaper?

YES NO

Does your child need assistance toileting? Please explain. (Pull-ups?

Diapers?) What can they do independently?

YES NO

Does your child need assistance eating or drinking? (sippy cup, straw, thickener) YES NO

Page 9 of 12

Is your child a runner? YES NO

Is your child able to board a bus independently? YES NO

Does your child wear a (harness) cam wrap or star seat while riding on the bus? If

yes, provide child’s height & weight

YES NO

Does your child use Augmentative and Alternative Communication (AAC)? For

example sign language, picture board, gestures, electronic device, etc.

YES NO

Does your child exhibit any inappropriate behaviors? YES NO

Do you suggest any calming techniques to use with your child? YES NO

Does your child have aggressive behavior toward others? YES NO

Does your child have any stress triggers? YES NO

****The Arc of Tippecanoe County and Camp SPARKS are not liable for any loss or damage to equipment during camp hours and outings. Staff will be diligent in monitoring and protecting equipment but cannot be responsible for accidental breakage or loss.

Page 10 of 12

Dear Camp Parents,

Thank you for choosing The Arc of Tippecanoe County’s Camp SPARKS for your child. We appreciate the opportunity to provide your child with the best camp experience possible.

As most of you know, Camp SPARKS is always looking for sponsors to continue to keep our costs to families as low as possible. We also use these funds to provide scholarships and to cover the additional costs for Camp not covered by camp fees.

If you know an individual, organization or business that would be interested in sponsoring Camp SPARKS please share the attached Sponsorship letter with them. A donation of any size is appreciated.

Thank you again for partnering with us. When we all pull together, great things happen.

See you soon at Camp!!

Milissa O’HernExecutive DirectorArc of Tippecanoe County

Page 11 of 12

Greetings!

Summer camp, whether it was magical, awkward or fun, forms strong memories during childhood. The Arc of Tippecanoe County’s Camp SPARKS is a summer day camp for all children ages 5-17. Camp SPARKS has provided an inclusive camp experience to the children of Tippecanoe County for over 40 years. Children with disabilities are accommodated and supported in the traditional camp environment and participate alongside their non-disabled peers and siblings. Campers have fun in an environment that promotes social skills, independence, builds self-esteem and creates friendships. The Arc of Tippecanoe County strives to promote a positive image of people with disabilities in our community through education, advocacy and multiple social programs for people of all ages. Camp families are encouraged to invest in their child’s camp experience. However, most of these families struggle due to the financial challenges of having a child with special needs. The cost of camp is $350 per camper, which represents about one third of the total cost for each camper to attend the four-week camp. Thanks to sponsorships from individuals, organizations and local businesses, we are able to offer assistance to families with true financial need. Sponsorship dollars also cover the cost of staff, transportation, field trips and other needed supplies.

Camp Sponsors will be recognized with their logo/name on our 2016 Camp SPARKS t-shirts, at our annual end of camp picnic on July 22nd and will also have the opportunity to visit camp to see your dollars at work. Your contributions may be tax deductible; please consult your financial advisor.

Checks should be made payable to The Arc of Tippecanoe County. Write the camper’s name in the memo line if you wish to sponsor a specific camper. You may also choose to sponsor a field trip or event. All contributions can be mailed to: The Arc of Tippecanoe County, Attn: Camp SPARKS Sponsorship, PO Box 1222, Lafayette, IN 47902-1222.

Thank you for your consideration and support. To learn more about The Arc of Tippecanoe County’s Camp SPARKS and other social programs please visit The Arc of Tippecanoe County’s website at www.arcoftippecanoe.org. If you have any questions or would like to speak with someone about sponsorship please contact me at 765-476-3277 or by email at campsparks@arcoftippecanoe.org.

Sincerely,

Milissa O’HernExecutive DirectorArc of Tippecanoe County

Page 12 of 12