Next Step s Face Forward Conference 2012 Participant Application Packet

Transcription

1 Dear Participants and Parents/Guardians, Next Step s Face Forward Conference 2012 Participant Application Packet Welcome to the 2012 application for Next Step s Face Forward Young Adult Conference! This conference provides teens/young adults (age 16 to 24) living with metabolic/genetic conditions an opportunity to come together for four days of fun and adventure. Please read all the information enclosed as our registration has changed somewhat. This year s program will be held at the campus of Bentley University, Waltham, MA from July 8 th July 12 th. Attendees will be arriving at 5 pm on Sunday, July 8 th and picked up at 2pm on Thursday, July 12 th. Please be aware these times could change. Exact times will be confirmed with participants after they have applied and been accepted. The activities planned will engage you, excite you, and maybe even push you a little bit outside of your comfort zone. There s no doubt we will encounter additional fun and adventure along the way, so be ready! Because some teens with metabolic/genetic conditions must follow strict diets, specialized food will be available to meet everyone s dietary needs. Formula will not be provided. Please be sure to bring enough formula to last the duration of the trip. You should also bring mixing containers. Refrigeration will be available. There is no cost for the program, which includes all food, lodging, and planned activities. To secure your participation in the program, a $50 deposit is requested upon registration and can be returned to you at the end of the program or you may donate your deposit to Next Step s Face Forward Project. Applications are due June 29th, Participants are accepted on a first-come, first-serve basis. If your application is received after the program is full, you will be placed on a waiting list and will be notified when/if a space becomes available. Please write checks to Next Step. Completed application form and check should be mailed/faxed to: Next Step Face Forward A Sherman Street Cambridge, MA or Fax: Attn: Face Forward Registration or digital application to: faceforward@nextstepnet.org Questions? Please contact Mallory Cyr mal@nextstepnet.org or Jessica Martin jess@nextstepnet.org or Bill Kubicek- blk@nextstepnet.org or

2 PART I: GENERAL INFORMATION APPLICANT Name Daytime Telephone ( ) Gender Male Female Evening Telephone ( ) Age DOB / / Cell Phone ( ) Address City/State/Zip PARENT/GUARDIAN Name Home Telephone ( ) Work Telephone ( ) Cell Phone ( ) EMERGENCY CONTACT (other than parent/guardian) Name/Relationship Daytime Telephone ( ) Evening Telephone ( ) Cell Phone ( ) FAMILY PHYSICIAN Name Telephone ( ) Fax ( ) INSURANCE INFORMATION Please attach a photocopy of both the front and back of your insurance card. Insurance Company Prescription Plan # Policy # Telephone # PART II: MEDICAL INFORMATION Genetic/Metabolic Condition Other Medical Condition(s) Hospital Affiliation Diet (please describe dietary restrictions) Formula (what kind? Dosage?) Medications ALLERGIES (including environmental and food allergies) NONE Allergy Reaction Medication (if any) Do you carry an Epi-Pen? Yes [] No [] CURRENT MEDICATIONS (including psychiatric, over-the-counter, inhalers, herbal supplements) NONE Medication Taken For:(symptom/condition) Dosage Started Current Side Effects 2

3 PART III: HEALTH PROFILE # Please one - If yes, describe below Y N # Please one - If yes, describe below Y N 1 Seizure within the past 1 year 6 Use of tobacco/smoker 2 Hospitalization/Emergency Room/Urgent Care visit within the past 1 year 7 Current neck/back/shoulder/knee/ ankle/or other joint problem 3 Asthma (if yes please bring inhaler) 8 Bedwetting 4 Unexplained chest pain/pressure, shortness of breath, rapid heartbeat, sweats, or dizziness/lightheadedness on exertion. 5 Other cardiac conditions, e.g., heart murmur or other rhythm abnormality # Describe # Describe 9 Diagnosed learning disability and/or ADD/ADHD 10 Other medical issues/illnesses/ symptoms/requirements PERSONAL HISTORY Have you been diagnosed or treated for any of the following within the past 2 years? Attention Deficit Disorder (ADD) Eating Disorder Personality Disorder 1 Adjustment Disorder Impulse Control Disorder Schizophrenia Anxiety Disorder Learning Disorder Substance Related Disorder Disruptive Behavior Disorder Mood Disorder 2 Have you received treatment or therapy for any of the above conditions? Medication(s) Day Treatment Hospitalization Outpatient Counseling Residential treatment 3 Are you currently (or within the past 1 year) taking medication(s) to treat any mental health issues? YES NO 4 Have you experienced any of the following significant events within the past year? Serious illness Self harm Incarceration Serious accident/injury Expulsion Death of relative/friend PART IV: SIGNATURE REQUIRED Consent is hereby granted for applicant to attend Next Step s Face Forward Conference 2012 and permission is given for any emergency anesthesia, operation, hospitalization, or other treatment that may become necessary. All information will remain confidential. You should know that over the years, many participants with a variety of medical/psychological conditions have successfully completed our program, but we must be aware of these conditions. Failure to disclose such information could result in serious harm to you and your fellow participants. Parent s/guardian s Signature (if participant is under 18) Participant s Signature 3

4 86a Sherman Street, Cambridge, MA CONSENT AGREEMENT, AUTHORIZATION AND RELEASE This Consent Agreement, Authorization and Release must be read and signed to be eligible to attend the Face Forward Conference. Participant's full name: Phone: Address: City: State: ZI:P RELEASE OF LIABILITY I understand that occasionally accidents occur during retreat activities and that participants may sustain serious personal injury and property damages as a consequence thereof. Knowing the risks of retreat activities, nevertheless, and in consideration of my acceptance for participation at a retreat, I hereby agree to assume those risks and to hold harmless Next Step and all retreat agents, representatives, employees and volunteers, from any and all liability, claims for personal injury and/or property damage, costs, expenses and damages arising out of or connected in any way with my participation in retreat activities. Further, I acknowledge that Next Step accepts no responsibility for the loss, damage or theft of my personal property. CONSENT FOR MEDICAL TREATMENT The undersigned hereby grants permission to the medical staff or consulting physicians at the Face Forward Conference to administer medication and provide medical care for me, including any medical emergency care required. I also give my consent for any emergency transportation deemed necessary. PHOTO AND INFORMATION RELEASE I give Next Step permission to photograph and use pictures or visual and/or audiotapes of me in professional or fundraising activities. On occasion, with this permission, participant photographs may be included on the Next Step website, on a bulletin board, video, newsletter, retreat album, or in personal photographs. Next Step respects the privacy of participants and does not allow unauthorized visitors to photograph the retreat or participants. In addition, by signing below, I give Next Step permission to give my name, address and/or phone number to groups or individuals wishing to support Next Step by inviting me to an event or by sending me information related to Next Step. This list will not be sold or given to anyone else for any other reason. I agree to the photo release I do not agree to the photo release Parent/Guardian s Signature (if participant is under 18) Parent or Guardian s Name (Printed) : Participant s Signature Participant s of Birth : 4

5 Next Step s Face Forward Conference 2012 Community Agreement The young adult conference is a close-knit community, therefore we ask that you agree to a few things that will promote being together in a safe and sound manner. Please sign this Community Agreement, which asks that you conduct yourself ethically while living in community, for the safety and well-being of yourself and others. We ask that you agree to the following: I will take into consideration the rights and feelings of others and respond to them in an open and caring manner I will stay drug -free except for prescription drugs or over-the-counter medications I will not lie, cheat or steal, or tolerate such behavior from others I will not take unnecessary risks or encourage others to do so I will not engage in any sexual activities I will not abuse the facility nor will I harm other people's possessions Adhere to your dietary restrictions (if applicable). Diet-appropriate food (in most cases, lowprotein) will be provided for all participants. All pertinent nutritional information will be provided as well. Staff will support participants in adhering to their dietary restrictions, but ultimately participants are responsible for their own choices. Adhere to your formula routine (if applicable). Each participant must bring his/her own formula enough for the entire weekend. Appropriate formula storage will be provided, and participants will have opportunities to mix formula as they normally do. Staff will provide the group with prompts for taking formula, but ultimately participants are responsible for drinking their formula. Adhere to your medication regimen (if applicable). Staff can assist with this, but parents and participants should make these arrangements ahead of time. Consequences for a broken contract will be determined by the director. You will be held responsible for any damages incurred if dismissed from the retreat. Thanks for understanding, and for ensuring a fun, safe and enriching experience for everyone. Printed Name: Signature 5