WIXLIB

Genesis Therapeutic Riding Center ofWest Calcasieu Cameron HospitalPh: (337) 625-3972Fax: (337) 625-5722886 Landry LaneSulphur, Louisiana 70663(Fishing, Arts-n-Crafts, and Equestrian Skills)Dear Parents/Guardians,Camp Smiling F.A.C.E.S. 2019 will be held 6/17/19 - 6/21/19 from 8 a.m. – 12 p.m. each day.The cost of the camp is 75.00 per child and will cover the costs associated with the camp’s variousactivities. If you would like to enroll more than one child, please contact us for further details. Activitiesinclude horseback riding, fishing, socialization, and arts-n-crafts.In order to promote self-sufficiency this year, the staff is asking participants to use the attachedCamp Sponsorship-A-thon form, and actively ask friends and family to sponsor their child. Checksshould be made payable to West Calcasieu Cameron Hospital’s Camp Smiling F.A.C.E.S.If your child requires a specialized helmet, hearing aids, medications, special equipment, fooditems, insect repellent, sun screen, diapers, or any other item, please be sure to send those items with themto camp, along with instructions. Campers are to be dropped off in front of the barn, in a single-file line(please do not get out of your car), starting at 7:30 a.m. Campers are to be picked up at 12 p.m. each dayin the same manner. Please – no early birds. In addition, anyone picking up a child MUST be listed onthe pick-up form and have a form of identification.AS HORSEBACK RIDING IS PART OF THE CAMP, CLOSED TOE SHOES AREREQUIRED. ANYONE WEARING FLIP FLOPS OR SLIP ON SHOES WILL NOT BEALLOWED IN THE BARN AREA. ALSO, SHORTS ARE TO BE WORN UNDER ALL SKIRTS.Limited space is available. All applications must be received by May 31, 2019, and aretaken on a first come, first served basis. Please mail or drop off the original documents and fees to:Genesis Therapeutic Riding Center of West Calcasieu Cameron HospitalCamp Smiling F.A.C.E.S.886 Landry LaneSulphur, LA 70663If you have any questions, please call the Genesis Therapeutic Riding Center at (337) 625-3972.Sincerely,Genesis Therapeutic Riding Center Staff

Genesis Therapeutic Riding Center ofWest Calcasieu Cameron HospitalPh: (337) 625-3972Fax: (337) 625-5722886 Landry LaneSulphur, Louisiana 70663(Fishing, Arts-n-Crafts, and Equestrian Skills)Important Notice to Parents/GuardiansApplication Process:Complete and return the following forms:1) Camper Application form (2 pages)2) Medical Form (completed and signed by licensed physician only, not byparent/guardian)3) Release Form4) Copy of insurance card (front and back)5) Copy of specific diet (if applicable)6) Pick-up Form7) 75.00 Camp Fee (if you have multiple children, please call (337) 625-3972)8) SPAR Water Park permission slipEligibility:All acceptances are conditional! Camp Smiling F.A.C.E.S. has the right and obligation tosend a camper home due to health, medical, or behavioral reasons. Predicting the camper’sreaction to the camp experience may be difficult, therefore, parents or guardians must beaccessible at all times during the camp session.Initial consideration for acceptance is a special needs child between the ages of 4 and 12years old (if child is not between ages 4 and 12, please speak with staff for consideration). Thismay include, but is not limited to, autism, amputee, epilepsy, spina bifida, cerebral palsy, visualdeficits, brain damage, developmental delay, muscular dystrophy, downs syndrome,speech/hearing impairment, and other disabilities. This does not include emotional or behavioralproblems. Inappropriate behavior may include hitting, kicking, biting, hair pulling,inappropriate sexual behavior, or swearing exhibited toward other campers orstaff/volunteers. This type of behavior is a safety issue and takes away from the purpose of thecamp experience.Additional factors regarding acceptance may be medically based such as against physician’srecommendation, continuous tube feeding, etc. Snacks will be provided, but if your child is on aspecial diet, you may need to furnish the appropriate foods.Weight capacity for riding horses cannot exceed 150 lbs.Safety Guidelines for Camp Participation:In order to ensure a safe and positive camp experience for all campers, staff, and volunteers, eachcamper must meet the following guidelines to be eligible to participate:- Does not have a history of or demonstrate excessive verbal abuse.- Does not have a history of or demonstrate physical aggression (i.e. hitting, kicking,spitting, biting, and scratching).- Does not have a history of or demonstrate inappropriate sexual behavior (i.e. sexual touchor comments towards others or self).- Does not have a history of or demonstrate uncontrolled grand mal seizures- Does not have a history of or demonstrate any behaviors that may place campers, staff, orvolunteers at risk.- Able to participate safely in a small group setting. If more supervision is needed, theparent/guardian may be required to provide an aide (paraprofessional).DeadlinesFriday, May 31, 2019 NO EXCEPTIONS – application(Due to number of staff the first 30 approved applications will be accepted only)Please Mail/Drop off Original Documents to:Genesis Therapeutic Riding Center of West Calcasieu Cameron Hospital886 Landry Lane Sulphur, LA 70663

Genesis Therapeutic Riding Center ofWest Calcasieu Cameron HospitalPh: (337) 625-3972Fax: (337) 625-5722886 Landry LaneSulphur, Louisiana 70663(Fishing, Arts-n-Crafts, and Equestrian Skills)Return form to above address. Please answer all questions completely, as thisinformation will be used to provide a safe and enjoyable experience for the applicant.Note: If your child is unable to sit astride a horse due to contraindications, other horse related activities can be provided.IDENTIFICATIONAgeSex F MApplicant’s Name Date of BirthAddress City State ZipGuardian’s Name RelationshipPhone Cell/pager WorkALTERNATE EMERGENCY CONTACT: (other than guardian listed above)Name RelationshipPhone Cell/pager WorkSCHOOL INFORMATIONSchool attends GradeHEALTH INFORMATION (This information is only in case of an emergency)Health/Accident Insurance Policy No.Group No. Medicaid No.*Please attach a copy of insurance/medicaid cards.Primary Physician PhoneAddressNature of DisabilityDoes the applicant have a disability: YESNOIf yes, then please check all that apply: Amputee Multiple SclerosisMental Ability: (check one) Autism Developmental Delay Normal function Epilepsy Muscular Dystrophy Learning disabled Spina Bifida Down Syndrome Mildly MR Cerebral Palsy Speech Impairment Moderately MR Visual Deficits Hearing Impairment Severely MR Brain Damage Profoundly MR Other disability:Allergies: Food, medicines, insects, plantsYES NO Explain:List any physical or behavioral conditions that may affect or limit full participation in fishing, horsebackriding, and/or vigorous group games:OFFICE USE ONLY:Date Rec’d Date approved Amt. Fee rec’d Date Rec’dConfirmed by Phone Letter In person Declined secondary toNote:Page 1 of 2

Genesis Therapeutic Riding Center ofWest Calcasieu Cameron HospitalPh: (337) 625-3972Fax: (337) 625-5722886 Landry LaneSulphur, Louisiana 70663Applicant’s Name:Check all items that apply, past or present, to applicant’s health history. If YES, explain.General:YESNOYES NOYES NOShunt Convulsions/Seizure Hemophilia Asthma Diabetes High Blood Pressure Contractures Heart Trouble Fainting spells Contacts/glasses Scoliosis/Kyphosis Deformity Explain:Please list ALL medications:List any medications to be taken at camp:Summarize applicant’s operations/surgeries or serious injuries with dates:Immunizations: (Give date of last inoculation)Tetanus toxoidMeaslesDiphtheriaMumpsChicken PoxRubellaMobility walks alonePolioPertusis walker/crutches electric wheelchair manual wheelchairCan applicant move by self? Yes NoTransfers no assistance needs assistance How much?Can applicant bear weight when standing? Yes NoSitting (example no assistance needs assistance How much?Sitting tolerance: 15 min 30 min over 60 minedge of bed)AssistiveDevicesCommunication none helmet braces prosthesis oxygen glasses hearing aid wheelchair otherDoes applicant have difficulty expressing thoughts or wants? Yes NoDoes applicant use: communication board computer gestures sign language otherEating no assistance partial assistance total assistance special utensils:Diet normal chopped food blended/pureed low calorie low salt diabetic peg tube food allergies special diet (please attach specifics on separate paper; not all special diets canbe met at camp you may however pack your child’s snack if needed) always sometimes needs reminders incontinent needs assistance on schedule:Bowel ControlBladder Control always sometimes needs reminders incontinent needs assistance on schedule:Aids Used catheter (type: ) urinal special toileting chair diapers/special undergarment other:(bring to camp ifappropriate)Applicant’s T-shirt size: (circle one) youth adultWhere did you hear about our camp?OFFICE USE ONLY:Date Rec’d Date approved Amt. Fee rec’d Date Rec’dConfirmed by Phone Letter In person Declined secondary toNote:Page 2 of 2

Genesis Therapeutic Riding Center ofWest Calcasieu Cameron HospitalPh: (337) 625-3972Fax: (337) 625-5722886 Landry LaneSulphur, Louisiana 70663(Fishing, Arts-n-Crafts, and Equestrian Skills)Medical Evaluation and ReferralReturn form to above address.NOTE TO LICENSED HEALTHCARE PRACTITIONER: The applicant/person being evaluated will beattending a one-week camp that may include participating in strenuous activities such as horsebackriding, fishing, and vigorous group games. The camp is 4 hours long each day for 5 days. Safetyequipment and specially trained horses, medical personnel, and volunteers will be used. In order toassure the fullest possible protection and greatest personal benefit from the camp, each applicant isrequired to furnish the following medical information before being accepted.NOTE: BECAUSE OF THE NATURE OF THE ACTIVITY OF HORSEBACK RIDING, NO INDIVIDUALDIAGNOSED DOWN’S SYNDROME CAN BE ACCEPTED FOR RIDING INSTRUCTION WITHOUT PROOF OF ANEGATIVE DIAGNOSTIC X-RAY FOR ATLANTOAXIAL DISLOCATION CONDITION.Name: Date of Birth:PHYSICAL EXAMINATION (To be filled out by a licensed physician)Diagnosis: Date of Onset:IF THE DIAGNOSIS IS DOWN’S SYNDROME, THIS FORM MUST BE ACCOMPANIED BY: a signed,dated statement from a qualified physician giving the date and result of a diagnostic X-ray forAtlantoaxial Dislocation Condition.Height:Weight:B/P: /Pulse:VISION: Normal Glasses ContactsHEARING: Normal AbnormalExplain:Check box:N AbnN AbnN AbnGrowth development Teeth Genitalia Cardiopulmonary system Skin Musculoskeletal HEENT Hernia Neurobehavioral Coordination Sight Mobility Neuro-sensation Seizures Muscle Tone Explain if abnormal:Diet Restrictions:Surgical Procedures:Medications:Medical History:Recommendations (explain any restrictions OR limitations):IN MY OPINION, THE PATIENT NAMED MAY ATTEND THE CAMP AND RECEIVE RIDINGINSTRUCTION UNDER APPROPRIATE SUPERVISION.Physician’s SignatureAddressDatePhone