2010 Challenge by Choice

Participant Information

First Name:

Last Name:

Address:

City:

State: Select State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Home Phone:

Cell Phone:

Email:

Age:

Sex: Select Male Female

Height:

Weight:

Birthdate:

T-shirt Size: Select S - Male M - Male L - Male XL - Male XXL - Male S - Female M - Female L - Female XL - Female XXL - Female

Guardian Information

First Name:

Last Name:

Address 1:

Address 2:

City:

State: Select State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Home Phone:

Other Phone:

Relationship:

Email:

Other Emergency Contacts

Please be sure these people will be available during the week of camp.

Emergency Contact One

First Name:

Last Name:

Address 1:

Address 2:

City:

State: Select State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Home Phone:

Work Phone:

Relationship:

Emergency Contact Two

First Name:

Last Name:

Address 1:

Address 2:

City:

State: Select State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Home Phone:

Work Phone:

Relationship:

Additional Information

Medical Power of Attorney:    Yes No

Phone:

Current Physician:

Phone:

Medical Insurance:    Yes No

Your Injury

Date of your injury:

How old were you:

Explain your injury:

Mobility

Mobility:    Select Walks Independently Manual Wheelchair Electric Wheelchair Walker Cane Crutches Other

If in a wheelchair:

Do you use the chair:    Select All the time Just when fatigued Just outside Not at home, just camp Not at camp

Operate the wheelchair independently:    Yes No

Transfers:    Select No Assist Total Assist Pivot with Spotter Other

Other:   

Weight shifts:    Yes No

Do you have balance concerns:    Yes No

Do you have walking concerns:    Yes No

Require assistance on rough, uneven terrain:    Yes No

How far can you walk:   

Climb up and down stairs independently:    Yes No

Other Adaptive Devices

Other Adaptive Devices:    Select None Night Braces / AFO's Prosthesis Helmet Glasses / Contacts Hearing Aid Dentures Other

Other - Explain:   

Seizures

Seizures:    Yes No

Speech Concerns

Speech Concerns:    Select Normal Mildly Affected Moderately Affected Severely Affected Few Words Non-Verbal

Communication

Speech Concerns:    Select Speaks Uses Sign Language Uses Communication Board Uses device Gestures Other

Other:   

Can you understand what is said to you:    Yes No

Can you express your needs:    Yes No

Do you know sign language:   

Hearing

Select Normal Hard of Hearing Wears Hearing Aid Sensitive to 'excessive' noise Extremely sensitive

Vision

Vision:    Select Normal Legally Blind Total Loss No Peripheral Vision Wears Glasses Contacts Other

Other:   

Are you sensitive to light:    Yes No

Vitals

Heart Problems:    Yes No

Heart Murmer:    Yes No

Irregular Heart Beat:    Yes No

Blood Pressure Concerns:    Yes No

Other:   

Experienced problems at higher elevation:    Yes No

Behavior

Memory:    Select It's Ok Mild Short-Term Loss Severe Short-Term Loss Extreme STM Loss

In a New Situation do you:    Select Get Lost Lose Belongings Run Away Wonder Off

Anger Issues:    Select None Mild Sometimes Severe Often

What Causes it?:   

What helps to calm you down:   

Frustration:    Select Never Sometimes Occasionally Often

Cause:   

Depression:    Select Never Sometimes Occasionally Always

Controlled by meds:   

Paranoia:    Select Never Sometimes Occasionally Always

Controlled by meds:   

Fears:   

Do you ever lose verbal contol:    Yes No

Do you ever lose physical contol:    Yes No

Are you currently receiving Psychotherapy:    Yes No

Personal Hygiene

Washing/Showering:    Select No Assist Partial Assist Total Assist Uses Shower Chair Just Needs a Shower Bar

Needs assistance with:    Select Hair Teeth Shaving

Explain:   

Dressing:    Select No Assist Partial Assist Total Assist

Explain:   

How long do showers & dressing normally take:   

For women: Do you need assistance with feminine products:    Yes No

Pads Tampons

Do you smoke: Yes No

What is your typical hygiene routine:    A.M.
P.M.

Toileting

Toileting:    Select No Assist Partial Assist Total Assist

Bladder needs:    Select None Incontinent Needs Reminders Needs to go very often

Explain:   

Bowel needs:    Select None Incontinent Needs Reminders Needs to go very often

Explain:   

Please list toileting schedule:   

Describe behavior related or disruptive toilet habits:   

How long does bowel routine take normally:   

Anger Issues:    Select None Urinal PM Urinal Catheter PM Catheter Toilet Chair Diapers PM Diaper Ostomy Bag Bedpan

Suppositories-when:   

Enema-when:   

Other:   

Sleep Routine

Do you require a nap:    Select Never Sometimes Once a day Only when very active I rest only

Do you feel fatigued:    Select Feel Fine Not Usually Sometimes Only Occasionally Severely-all the time

Do you have trouble sleeping:    Select No Yes If it is noisy I need a light on I need total darkness In a new place

Do you need to be awakened or turned at night:    Yes No

When do you usually wake up:   

When do you usually go to bed:   

Special routine:   

Eating

Eating:    Select No Assist Partial Assist Total Assist

Food must be:    Select Cooled Down Cut-Up Mashed Pureed Liquefied

Other:   

Aids Used:    Select Straw Feeding Tube Adaptive Utensils

How quickly do you eat:    Select Average Speed Fast Slow Very Slow Extremely Slow

Eating or swallowing concerns:   

Dietary Concerns

Dietary needs:    (you must supply any special needs)

Allergies:    Yes No

Dislikes:    Yes No

Religious dietary needs:    Yes No

Vegetarian:    Yes No

Medication & Health Record

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Medication:   

Taken for:   

how taken:   

as of (todays date):   

Over the counter ANYTHING:   

Doses:   

Vitamins and Herbs:   

Doses:   

*Should your medications change before camp-it is your responsibility to let us know!!!

What are you doing when you're not at camp?

Where do you live:    Select Own Home With Family Apt. Alone Group Home Apt with Roomate Assisted Living Facility

Are you currently involved in a day program:    Yes No

Are you in school:    Yes No

How do you get around:    Select Walk Bike Drive Bus Special Transit Arranged Rides Wheelchair

Some FUN Questions

Do you sing:    Yes No

Do you play an instrument:    Yes No

If so, feel free to bring it!!

Do you like jokes:    Select I like to hear them I like to tell them

Do you like stories:    Select I like to hear them I like to tell them

Your favorite activity/Hobbies Inside:   

Your favorite activity/Hobbies Outside:   

Tell us about YOU:   

Character References

Please provide 2 character references. (Required)

Name:   

Relationship:   

Phone:   

Name:   

Relationship:   

Phone:   

Camp Questions

I am applying for:    Select April Fools Winter Happening Easter Seals BOEC Canoe Trip Creative Minds

Years I have attended Easter Seals:   

Years I have attended BOEC - Challenge by Choice:   

Years I have attended BOEC - Canoe:   

Years I have attended BOEC - Creative Minds:   

Camps I have attended:   

How many years:   

Agreement, Consent & Release

With the understanding that the Easter Seal’s Camp Summit and the Breckenridge Outdoor Education Center will make every reasonable effort to prevent accidents, injuries or other mishaps, I acknowledge the following

The undersigned gives The Brain Injury Alliance of Colorado (BIAC) permission to verify any information on this application for attendance at a camp sponsored by the BIAC (camp) and to contact references, case managers, and emergency contacts for any further information which may be necessary. The undersigned agrees to indemnify and hold harmless the BIAC for any and all claims, demands, costs, expenses, including reasonable attorney’s fees, that the BIAC may suffer as a result of any claim, action, demand or judgment against it arising from the attendance at camp by this applicant. Provided, however, that the above and foregoing shall not be construed to indemnify the BIAC from any act of negligence or fault on the part of the BIAC, its officers, agents or employees. The undersigned does _____ or does not ______consent to having photograph(s) or video(s)taken of the named applicant during the camp period, and to said photograph(s) and video(s) being published in newspapers, magazines, television, publicity releases and/or other media. The undersigned, in case of an emergency involving the applicant and in the event the designated emergency contact cannot be reached by telephone, does hereby give permission for medical treatment which is necessary or desirable in the absolute discretion of any camp registered nurse or interns who possess a medical background. This medical care shall include, but is not limited to, examinations, treatments, immunizations, injections, anesthesia, surgery and other procedures, etc. The undersigned does hereby agree to allow the applicant to participate in all camp activities (except those specifically restricted). The undersigned gives permission for the applicant to ride in vehicles operated or leased by the BIAC, Easter Seals or Breckenridge Outdoor Education Center. The undersigned recognizes the right of the Camp Director, or the BIAC Lead, in his/her discretion, to terminate a camper or volunteer’s stay at any time due to disciplinary or medical actions which might jeopardize their own health or safety, or other’s health and safety at camp. The undersigned further agrees to pick up the camper or volunteer immediately upon being notified of such termination. The undersigned agrees not to send the applicant (to attend or volunteer), one of the BIAC Outdoor Adventure programs if he/she has been exposed to a contagious disease within three (3) weeks of the starting of camp, and to notify the BIAC if such a case should arise.

I agree

Challenge by Choice 2010

Please select the event you would like to attend below.

Breckenridge, Colorado (18 yrs. or older to attend)

April Fools - April 7-10: $850 100

Empire, Colorado (21 yrs. or older to attend)

Camp Summit - May 30-June 4: $810 100

Breckenridge, Colorado (18 yrs. or older to attend)

Challenge-by-Choice - June 6-11: $1700 100

Denver Day - June 19: $140 (15 yrs. or older) 100

Challenge-by-Choice - July 11-16: $1700 100

Challenge-by-Choice - August 1-6: $1700 100

Extreme Adventure Camp - August 22-27: $1700 100

Denver Day - August 29: $140 (15 yrs. or older) 100

Canyon Canoe Trip - September 1-5: $850 100

Creative Minds - September 10-13: $800 100

YES! Please send me a Scholarship Application!

Scholarships are limited, if you are able to pay the full tuition to please do so.
(You may attend more then one Challenge by Choice program, but only one can be scholarshipped.)

Billing Information

Credit Card #

Exp. Date: (10/2009)

Card Code: whats this?

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