Access the Dream 2015

Transcription

1 There are two Institutes being held this year. I will attend: June 11 14, 2015 in Alabama June 18 21, 2015 in Kentucky Mentors must have both vision and hearing loss, and a formal communication system and must have attended a Transition Institute previously. Name: Address: Do you go to college? If yes, what is the name of your college and what year are you in? If you are not in school, are you working? If yes, where do you work? How may we contact you at the Institute? Cell phone, pager, ? Type your cell phone, pager or address: Preferred Diet: Responsible Person Accompanying Mentor Information: Parents of Mentors are welcome to attend the institute, but Mentors are not required to have an accompanying adult. If no family member, SSP, or accompanying adult is attending with you, please put the name of the Deafblind Project person from your state. Please list parent name and contact below whether or not they are attending. Parent Name: Parent s Emergency Contact: Page 1 of 12

2 Person Accompanying Mentor Information: (This person must also register as either a SSP or Family Member) Name address of responsible person accompanying participant: Day Phone Number ( ) -- Night Phone Number ( ) -- Cell Phone Number ( ) -- Address: Street Name Apartment # City: State: Zip Code: Mentor s Parent/Guardian Information if different than above: Name Parent Day Phone Number ( ) -- Night Phone Number Cell Phone Number (primary) ( ) -- ( ) -- Cell Phone Number (secondary) ( ) -- Address: Street Name Apartment # City: State: Zip Code: Page 2 of 12

3 Photo / Video Permission: We will be taking pictures and videos during the entire Transition Institute. Photos and video clips may be used for Deaf-Blind Project brochures, websites, presentations, and other public relations media in order to share information about the Projects activities, the Institutes, and document what we all learn by accomplishing this work together. Do we have your permission to take either photos or videos with you in them? Youth: YES NO Parent: YES NO Do we have your permission to use your photo or video with you in them for these described purposes? Youth: YES NO Parent: YES NO Print Media Preference: Please check one for your print media preference (i.e., program book): I need reading materials in: Regular print Large print Braille I need an assistive listening device: yes no If yes: I ll bring it I need you to bring a sound system. I use sign language and need an interpreter: yes no If yes: Close Vision Platform ASL Tactile Medical/Health Information: Please indicate medical conditions, including allergies, other than vision and hearing loss that we should know about: Include dietary restrictions and food allergies. Page 3 of 12

4 MENTOR COMMUNICATION PROFILE In order to provide the most supportive communication needs throughout the Institute, it is critical that a Communication Profile be completed for you. SSP Needs: SSP stands for Support Service Provider. Most SSPs provide visual and auditory information about the environment, human guide, and interpret. To help us coordinate SSPs before you arrive, please provide detailed information about the kinds of help you need travel, interpreting, voicing, etc. Please complete all boxes: Name: Age: Uses sign language interpreters: Yes: No: Mode of Communication Lipreading: Hearing Aids: FM System: Other: Sign Language American Sign Language: English like Signing: Total Communication: Other: Modifications Close Vision: Restricted Vision: Explain: Tactile Signing Left Hand: Right: Both: Conference Attendance Me/My young adult will attend conference presentations: Yes: No: Me/My young adult will need communication support: Yes: No: I am/my young adult is independent and can determine my/his/ her own schedule throughout the conference. Specific communication preferences: Support Service Providers (SSPs) I will use an SSP during this event: Yes: No: I have never used a Support Service Provider (SSP) in the past but Yes: No: would benefit. I will be bringing my/his/her own SSP. Yes: No: My SSP will also act as an interpreter for me: Yes: No: I need an SSP: always during meal times & transitions never Additional Information Other details that will assist us in providing the most appropriate communication supports to you/your young adult: Yes: No: Page 4 of 12

5 Additional SSP Needs: SSP stands for Support Service Provider. Most SSPs provide visual and auditory information about the environment, sighted guide, and interpret. To help us coordinate SSPs before you arrive, please provide detailed information about the kinds of help you need travel, interpreting, voicing, etc. I need an SSP: pretty much all the time for: at specific times, like: I need little or no help from an SSP, maybe only I m bringing an SSP with me. I need you to provide an SSP. When are you coming and how long are you staying? Please write the total number people who will need meals and/or accommodations for Thursday, Friday, Saturday and Sunday morning. (One adult (either parent or responsible adult) may accompany each young adult.) # of people arriving Thursday # of people staying Thursday, Friday and Saturday nights How are you getting to the Institute? I am coming with a family member or other adult. We are driving on our own to attend the Institute. We are flying and need someone to pick us up at the nearest airport. Arrival time/date: Airline and Flight #: Departure time/date: Airline and Flight #: Please call and let s set up who will pick me up. I am coming with a group from my state. Transportation is arranged by my deaf-blind project. Page 5 of 12

6 Code of Conduct Agreement: Mentor Name: DOB: Being a Mentor at these Institutes is an opportunity of leadership and supporting others to realize their greater potential. To that end, Mentors are expected to Lead by Example in their behaviors and actions. Therefore, they must also know the expectations of the Code of Conduct and possible Consequences of Misbehavior for which they are expected to demonstrate and help others uphold. All rules and regulations governing program activities and events will be discussed with all Project personnel, Institute Leaders, Mentors, Interpreters, Support Service Providers, Volunteers and Participants. The Deaf-Blind projects supporting these Transition Institutes are not responsible for the supervision of participants or Mentors. Minor participants (under the age of 18) must be accompanied by a parent or responsible adult. Participants and Mentors, including those over the age of 18, must agree to and obey to the rules and regulations specified in the Code of Conduct. Participants are expected to attend all event sessions as part of a planned program exhibiting positive character and behavior including (but not limited to) trustworthiness, responsibility, respectfulness, caring, citizenship and fairness. Participants are expected to be responsive to the reasonable requests of the leaders and respectful of the needs for their personal safety and the safety of others. Participants should dress appropriately, use appropriate language and respect the rights of others. Participants may not use alcohol, drugs, or tobacco, nor be associated with or remain in the presence of others using the substances. Participants may not behave recklessly, engage in sexual misconduct, assault, threaten or harm another person nor may they misuse or abuse public or private property. Participants may have access to computers and facilities. Computers use is for educational purposes. Participant may not access in appropriate websites. Realizing these guidelines are not all inclusive the Deaf-Blind Projects Staff reserve the right to make adjustments to these policies to ensure the safety of all participants. SSP S CANNOT PROVIDE THE FOLLOWING SERVICES: Teach, counsel, give advice or their opinions. Clean up after the consumer, walk or clean up after their pets. All service animals must stay with the Institute Participant for whom you are providing service at all times and may not be left alone or in the care of the SSP. Provide personal care services (Assist w/medication, Bathing, Feeding, etc.). Do errands without physically being accompanied by the Deaf-Blind person. Move personal items without communicating to the consumer. Page 6 of 12

7 CONSEQUENCES OF MISBEHAVIOR Participants and adults who observe a breach in the Code of Conduct should report the misbehavior to the appropriate leader. Participants misbehaving will have the opportunity to explain their actions to leaders in charge of the activity. Personnel in charge of the Institute will determine what disciplinary action should be taken. Any participant found in violation of the actions listed below will have his/her parents/guardians notified, and the participant may be sent home at the parents or their own expense: 1. Breaking curfew or disturbing the peace. 2. Unexcused absences from the activities of an event. 3. Reckless behavior. 4. Use of foul or offensive language. 5. Possession or use of tobacco. 6. Breach of the Code of Ethics. 7. Remaining in the presence of those using alcohol, illegal drugs, or tobacco. 8. Possession or use of illegal drugs or alcoholic beverages. 9. Theft, misuse, or abuse of public or personal property. 10. Sexual misconduct. 11. Possession of weapons or fireworks. 12. Unauthorized absence from the premise of the event. 13. Assault or personal harm. 14. Leaving premises without notifying the event Staff. MENTORS* & Participants AGREEMENTS: I have reviewed the Code of Conduct and agree to all of its provisions. *Mentors 18 years and older do not require parent signature. Mentor Signature Date I have reviewed the Code of Conduct and agree to all of its provisions. I certify that my child who is to be a MENTOR is participating in the Southeast Transition Institute with my knowledge and consent. I have read and understand all of the above policies. Parent/Guardian Signature Phone Date Page 7 of 12

8 Medical Information, Permission to Treat & Release of Liability Name Date of Birth Gender F M Address: Street Apt: City State Zip Parent/Guardian Information: Name Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Best Contact Number: ( ) - Please list the names of two adults other than parent/guardian who may be contacted in case of emergency: Name Cell ( ) - Home Phone ( ) - Work Phone ( ) - Name Cell ( ) - Home Phone ( ) Work Phone ( ) - Medical Information: Please indicate medical conditions, including allergies, other than vision and hearing loss that we should know about: Name of Physician: Is there a history of heart condition, high blood pressure diabetes asthma epilepsy rheumatic fever? Phone ( ) - Date of Last Physical Examination: Drug Allergies: Other Allergies: Describe any physical limitations: Describe any recent illness or injury: Special Diet related to health concerns: Page 8 of 12

9 INSURANCE COVERAGE INFORMATION Photo copy of insurance card must be included (Please copy front and back of insurance card) Insurance Holder (Employee) Name): Name of Insurance Provider: Group Name: Group Number: Over the Counter & Prescription Medication Summary: Mentor s Name Does you need assistance in taking medications? Please list all medication including over the counter medications. Additionally, Mentors of legal age, or parent/guardian should list any over the counter medication that may be taken or given to the participant in case of illness. Institute/Project personnel may not administer over the counter or prescription medication without parental/guardian approval unless prescribed by medical personnel. Mentors are expected to provide all medication(s) listed and administer the medication. Additional copies of this page may be made as necessary. I am the parent/guardian of and give permission for the (Name of child/mentor) Medications listed to be administered to my child as directed. (see next page) I am of legal age and responsible for taking medications myself. I do not need assistance. I am of legal age and am responsible for taking medications myself. I require assistance. Signature Parent/Guardian/Mentor 18 years and older Date Students over the age of 18 must provide a signature. Parents may sign below as a witness. Witness Relationship to Mentor Date Page 9 of 12

10 Medication List: All medications must be listed including aspirin, Tylenol, cold medications etc. Prescription medications must have participants name written on prescription bottle or package. Name of Medication: What illness/condition is medication being taken for: Describe dosage and special instructions: Is medication self-administered? YES NO Dates for administration: Name of Medication: What illness/condition is medication being taken for: Describe dosage and special instructions: Is medication self-administered? YES NO Dates for administration: Name of Medication: What illness/condition is medication being taken for: Describe dosage and special instructions: Is medication self-administered? YES NO Dates for administration: Name of Medication: What illness/condition is medication being taken for: Describe dosage and special instructions: Is medication self-administered? YES NO Dates for administration: Page 10 of 12

11 Release and Hold Harmless Agreement/Permission To Provide Medical Treatment Mentor s Name: DOB: In the event of an emergency, I authorize any Transition Institute Members, Agents, Volunteers, and/or Advisors to organize and administer any required medical treatment or first aid procedure, and/or take the above named child to a hospital emergency room for treatment. I realize and agree that it is the responsibility of each individual or family to provide his or her own medical insurance. The undersigned hereby forever releases, discharges, and covenants to indemnify and hold harmless the organizers of the Transition Institute *, its members, volunteers, sponsors or any other supporting agencies, any other person, firm, corporation charged or chargeable with responsibility, liability, their heirs, administrators, executor, successors, and assignees from any and all claims, demands, cost, expenses, loss of services, actions and causes of action belonging to the undersigned or arising out of any act or occurrence in connection with and particularly on account of all personal injury, wrongful death, disability, property damage, loss or damages of any kind sustained or that may hereafter be sustained arising out of the matter described herein or in consequences of the full and complete release of any and all claims. I have read and fully understand the above information and agree to these terms. Signed Relationship to Institute Mentor: Date This document must be signed by a parent or legal guardian if Mentor is under the age of 18. *The Transition Institute may include the following states as Core Planners or/and Participants: Alabama Initiative for Children and Youth Who Are Deaf-Blind, Alabama Institute for Deaf and Blind; Children and Youth with Sensory Impairments, (CAYSI), Arkansas Department of Education, Special Education; Florida and Virgin Islands Deaf-Blind Collaborative, University of Florida, the Board of Regents of the University System of Florida, The Virgin Islands Department of Education; The Georgia Sensory Assistance Project, Georgia State University, the Board of Regents of the University System of Georgia; Project Reach: Illinois Deaf-Blind Services, Philip J. Rock Center and School; Indiana Deafblind Services Project, Indiana State University; Kentucky Services for Children and Youth Who Are Deaf-Blind, University of Kentucky and KY-SPIN, PTI Project; Louisiana Deafblind Project for Children and Youth, Louisiana State University Human Development Center; Mississippi Hearing-Vision Project, The University of Southern Mississippi; New Jersey Consortium on Deaf-Blindness at Center for Sensory and Complex Disabilities, The College of New Jersey School of Education; North Carolina Project for Children and Young Adults Who Are Deaf-Blind, Exceptional Children Division, NC Department of Public Schools; Ohio Center for Deafblind Education; South Carolina Interagency Deaf-Blind Project, South Carolina School for the Deaf and Blind; Tennessee Deafblind Project (TREDS), Vanderbilt University; Virginia Project for Children and Young Adults with Deaf-Blindness; Texas Deafblind Project, Texas School for the Blind and Visually Impaired; West Virginia SenseAbilities, West Virginia Department of Education, Office of Special Education Page 11 of 12

12 AGREEMENT AND COVENT NOT TO SUE: Furthermore, I am aware that participation in this event includes risk including, but not limited to, transportation to/from event, theme park rides, sports and recreational games, ropes courses, water activities, hiking, as well as risks that are not foreseeable. For the sole consideration of the deaf-blind projects arranging for participation in the Transition Institute, I hereby release and forever discharge the Transition Institute* their members individually, and their officers, agents, volunteers, and employees from any and all claims, demands, rights and causes of action of whatever kind that I may have, either on my own behalf or in my capacity as a legal representative of my child or myself (individuals over the age of 18), arising from or in any way connected with my child s participation in Deaf-Blind Transition Institute events. I further covenant and agree that for the consideration stated above I will not sue any or all of the entities of the Transition Institute*, it s members individually, its officers, agents, volunteers, or employees for any claim for damages arising or growing out my child s participating in the program. I certify that my child is participating in Transition Institute event, with my knowledge and consent. I have read and understand all of the above. Signature: Parent/Guardian/ Individuals 18 years and older Date (Students over the age of 18 must provide a signature. Parents may sign below as a witness.) Witness (Parent/Guardian/Other) Relationship to Participant Date *The Transition Institute may include the following states as Core Planners or/and Participants: Alabama Initiative for Children and Youth Who Are Deaf-Blind, Alabama Institute for Deaf and Blind; Children and Youth with Sensory Impairments, (CAYSI), Arkansas Department of Education, Special Education; Florida and Virgin Islands Deaf-Blind Collaborative, University of Florida, the Board of Regents of the University System of Florida, The Virgin Islands Department of Education; The Georgia Sensory Assistance Project, Georgia State University, the Board of Regents of the University System of Georgia; Project Reach: Illinois Deaf-Blind Services, Philip J. Rock Center and School; Indiana Deafblind Services Project, Indiana State University; Kentucky Services for Children and Youth Who Are Deaf-Blind, University of Kentucky and KY-SPIN, PTI Project; Louisiana Deafblind Project for Children and Youth, Louisiana State University Human Development Center; Mississippi Hearing-Vision Project, The University of Southern Mississippi; New Jersey Consortium on Deaf-Blindness at Center for Sensory and Complex Disabilities, The College of New Jersey School of Education; North Carolina Project for Children and Young Adults Who Are Deaf-Blind, Exceptional Children Division, NC Department of Public Schools; Ohio Center for Deafblind Education; South Carolina Interagency Deaf-Blind Project, South Carolina School for the Deaf and Blind; Tennessee Deafblind Project (TREDS), Vanderbilt University; Virginia Project for Children and Young Adults with Deaf-Blindness; Texas Deafblind Project, Texas School for the Blind and Visually Impaired; West Virginia SenseAbilities, West Virginia Department of Education, Office of Special Education Page 12 of 12