Annual Enrollment Registration Packet

ANNUAL ENROLLMENT REGISTRATION PACKET
We are delighted that you have chosen to send your child to Dream Oaks Camp. In order for us to process your child’s Annual Camp Registration, we will need you to provide all of the items listed in the checkbox below. Space for each session is limited so we encourage all families to return registration forms as soon as possible in order to secure a spot on our schedule.

The forms are now online & fillable! Once the camp has received the required forms and your $50.00 non-refundable deposit for each session you have registered for, we will send an email acceptance letter and Family Camp Manual to confirm that your child has been scheduled for the session. Acceptance into the desired camp session(s) is not guaranteed and is contingent upon space availability and staffing.

We do offer scholarships for families that need financial assistance. Typically, we are only able to offer 1 scholarship per child for the summer camp season, if funding is available, we may be able to offer an additional scholarship. Families wishing to enroll their child in additional sessions would be responsible for the full cost of each additional session.

If you have any questions please call our office at 941-746-5659.
ANNUAL REGISTRATION CHECKLIST

(We must receive ALL of the following in order to register your child. Medical forms can be submitted at a later date, however, MUST be returned no later than 2 weeks prior to the start of camp.)
Session Sign Up Form (Select the camp session(s) you would like and indicate how you will be paying for the camp sessions.) Payment of $50.00 per session, per child, MUST be included with Session Sign Up ($50.00 non-refundable fee for each registered session to be applied to balance) Annual Enrollment Registration Forms Scholarship applicants must submit income verification Annual Medical Forms (The forms must be completed and signed by a physician annually. Must be received no later than 2 weeks prior to the start of the camp session. If the medical form is expired, you child can NOT attend camp.
Page 1 of 16

CAMPER INFORMATION
Name *

Last Name First Name
Date of Birth *

Month Day Year
Age *
Address *
City *
State *
Zip *
Gender *

Male Female
Height *
Weight *
Ethnicity (opt)
Primary Diagnosis and Medical History (including diagnosis, surgeries, etc): *
Page 2 of 16

PARENT/GUARDIAN INFORMATION
Name *

Last Name First Name
Address (if different from above)
City
State
ZIP
Home Phone
Cell Phone *
Work Phone
Email *
example@example.com
Relationship to child *
Preferred method of contact *
Name

Last Name First Name
Address (if different from above)
City
State
Zip
Cell Phone
Work Phone
Home Phone
Email
example@example.com
Relationship to child
Preferred method of contact
Does the camper live in a foster home or group home? *

Yes No
If yes, please explain:
Page 3 of 16

EMERGENCY CONTACT INFORMATION

In the event you cannot be reached, please provide a local emergency contact.
Name *
Phone *
Relationship to child *
Name *
Phone *
Relationship to child *
Page 4 of 16

CHECK PROCEDURE & RELEASE

Camp staff will not release your camper to anyone other than the parent/guardian without prior authorization. I authorize Foundation for Dreams, Inc. & Dream Oaks Camp staff to release this camper to the following person(s):
Name *
Phone *
Relationship to child *
Is there any custody issue we should be aware of? *
Page 5 of 16

Behavioral Information
Please check all that apply *

History of verbal aggression Physical aggression/assaults peers or staff Self-injurious behavior History of elopement, running away or wandering away from home, program or school Camper requires one-to-one supervision at school Camper has unusual fears Other
Please explain all checked answers *
Other behaviors (please explain)
Has a Behavior Support Plan? *

YES NO
If yes, please explain and/or attach a copy of Behavior Support Plan and/or IEP
Attach Behavior Support Plan and/or IEP here

Cancel of
What precedes the behavior? Please explain
What intervention is used to correct the behavior? Please explain
What types of behaviors does camper exhibit when unhappy? Please explain *
Please explain how you handle camper's behaviors (i.e. positive reinforcements, activities that are calming, and rewards camper liked to work for): *
Page 9 of 16

Program Intake Form
Child Name *
Date *

Month Day Year
Date
We wholeheartedly believe that a child should be recognized as an individual, not by their disability. For this reason, each activity is designed to meet the specific needs of each camper by adapting strategies to highlight their strengths, not their limitations. By providing low direct care staff to camper ratios, staff can focus on modifying each activity and provide strategies to help campers grow their skillset and independence while building meaningful relationships in a safe enviroment!

It is our goal to collaborate with parents, teachers, and therapists so that there is fluidity between home, school, and camp. As a parent/caregiver, you may consider it helpful to have our staff continue to progress towards IEP goals that are compatible with the camp. Working towards specific targets at camp encourages development that can be sustained and grown across multiple settings.

We use research-based practices to monitor and facilitate specific targets for each child that fall within 4 domains:
1. Social Interaction: developing social understanding/awareness, engaging in appropriate play/interaction, understanding rules/emotions, increasing eye contact/verbalization, etc.
2. Activities of Daily Living: transferring/walking dressing, eating/preparing food, etc.
3. Health and Hygiene: bathing, grooming, oral care, toileting, increasing awareness/participation of medical needs, coping skills/emotional regulation, etc.
4. Behavior Strategies: transitioning, decreasing problem behaviors, following directions, self-monitoring, self-control, participation, etc.
Please list that you or your child's support team want staff to work on at camp:
1. Select specific target *
List specific goals *
2. Select specific target *
List specific goals *
3. Select specific target *
List specific goals *
Page 12 of 16

Participant Release Statement
ASSUMPTION OF RISK, RELEASE, AND WAIVER: I, as a consumer (camp participant), parent, guardian, or appointed representative of the consumer, understand the Foundation for Dreams, Inc. and Dream Oaks Camp, henceforth referred to as “FFD & DOC”, take reasonable efforts to operate and conduct activities in a safe and responsible manner. These recreational activities include, but are not limited to: arts & crafts, music, games, yoga, cooking, hiking, swimming, boating, playground equipment usage, vehicular transportation, and exposure to nature. I understand that these activities and the actions/or inactions of other program consumers involve certain inherent risks. I recognize these risks and agree to assume all liability for these risks by allowing the Consumer to attend FFD & DOC’s camp-based respite and other activities/programs participation in such programs and activities. I hereby release, indemnify and hold harmless FFD & DOC, its officers, agents, employees, and all consumer relating to or deriving in any way from participation in aforementioned programs and/or activities whether arising from an act of omission to the fullest extent permitted by law.
Initial *

Clear
MEDICAL RELEASE: I, as a consumer, parent, guardian, or appointed a representative of the consumer, authorize that in the event that an emergency should arise. I will accept and give permission for the Consumer to receive emergency care, offered by FFD & DOC/hospital for injury and/or illness. I acknowledge and agree that the designated first aid person/hospital in charge may perform emergency care and I hereby understand that medical care will be provided in accordance with the standard set forth by the Board of Medical Examiners of the State of Florida. I agree to assume financial responsibility for all expenses of such care. I authorize the FFD & DOC medical staff to dispense medications. I acknowledge that all medications administered by FFD & DOC staff must be brought to the program in the original packaging. Meaning prescription medications are original pharmacy packaging with labels indicating proper medication, dose, and time. All routine OTC medications are in original product packaging. I understand failure to comply with medication packaging requirements will mean dismissal from the program without refund. I release and absolve FFD & DOC, staff, nurses, physicians, and surgeons selected and designated, from any and all liability for their acts rendered in good faith. Parents/Guardians will be notified immediately of any treatment sought.
Preferred Hospital *
Reason
(Generally, in an emergency we use the closest hospital, but if an extenuating circumstance exists, we attempt to identify the preferred hospital and express the request to emergency medical personnel.)
Initial *

Clear
CANCELLATION AND PAYMENT POLICY: I, as a consumer, parent, guardian, or appointed representative of the consumer understand that FFD & DOC adheres to the following policy in regards to cancellations, payments, and refunds. A $50.00 non-refundable registration fee is due for each camp session the consumer is enrolled in at the time of enrollment. If the $50.00 is not received with the enrollment the consumer may not be registered for that session. For full payment consumers, the total balance is expected 14 business days prior to the camp session. A full refund or a credit for another camp session, minus the non-refundable $50.00 registration fee, may be given if written notice of the need to cancel is received by FFD & DOC at least one week prior to the start of the camp session. Other full refunds or a credit for another session, minus the non-refundable $50.00 registration fee may be applicable in instances where there is a medical emergency less than 24 hours prior to the camp session. We must receive notice of cancelation prior to 3:00 pm of the start of the camp session.
Initial *

Clear
My initials above indicate I have read, understand, and agree with each corresponding section of the release statment
Consumer Name (Camper) *
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Print Name *
Page 13 of 16

PERSONAL PROPERTY:

I, as a consumer, parent, guardian, or appointed representative of the consumer, recognize that FFD & DOC cannot accept responsibility for camper's personal property including but not limited to personal electronic devices. To help eliminate losses, the undersigned ensures that all clothing and belongings are labeled with camper's name and an Inventory of Personal Belongings form has been filled out and returned.
Initial *

Clear
MISSING PERSON'S RELEASE:

I, as a consumer, parent, guardian, or appointed representative of the consumer, hereby give consent to FFD & DOC to release photographs and other necessary information to the City and/or Manatee County Sheriff's Office and/or any other agency for the sole purpose of filing a missing person's report.
Initial *

Clear
ACKNOWLEDGE AND RELEASE TO FUNDING AGENCY:

I, as a consumer, parent, guardian, or appointed representative of the consumer, hereby acknowledge and release to the FFD & DOC my camper's records which may be required by a Funding Agency for purposes of monitoring and evaluating services.
Initial *

Clear
ACKNOWLEDGE AND RELEASE TO MANATEE COUNTY GOVERNMENT:

I, as a consumer, parent, guardian, or appointed representative of the consumer, understand that this program receives funding from Manatee County Government and that from time to time County representatives may request access to any or all Agency records relating to this program and/or the delivery of its services for the purposes of evaluating or monitoring the program or delivery of service. I understand that any records provided to the County shall become public records, may be subject to any applicable state or federal exemptions, and may be inspected by third persons.
Initial *

Clear
PHOTO/MEDIA RELEASE:

I, as a consumer, parent, guardian, or appointed representative of the consumer, hereby grant FFD & DOC permission to use any narratives, film, photographs, videotape, sound, and digital recordings of any kind made by FFD and DOC of the aforementioned consumer for the promotion of its programs and services in any publication or media outlet included websites entries, apps, social media platforms, and printed material, without payment or any other consideration. I understand and agree that these materials will become the sole and exclusive property of FFD & DOC. I irrevocably authorize FFD &DOC and its agents to edit, alter, copy, exhibit, publish, distribute or otherwise use any of the aforementioned consumer's likenesses derived above for the purposes of publicizing FFD & DOC programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product including a written or electronic copy, wherein my likeness appears. Additionally,I waive any right to royalties or other compensation arising or related to the use of any likeness. I hereby hold harmless and release and forever discharge FFD & DOC from all claims, demands, and causes of action which I, the aforementioned consumer, heirs, representatives, executors, administrators, or any other person acting on consumer's behalf of consumer's estate have or may have a reason of this authorization.
Initial *

Clear
ACCEPTANCE CONDITIONS:

FFD & DOC reserves the right to refuse to provide services to any individual if the camp staff determines that the individual cannot be provided with adequate support by DOC. These decisions are made on an individual basis. Parents/Guardians will be notified in the event of any serious injury or illness requiring more than basic first aid, or in the case of any significant incident or behavioral problem. The separate Health Examination Form which must be completed signed by a physician, M.D., must indicate that there is no evidence of any condition that might present health or safety risks to the camper, other campers or staff members. Should it become necessary for my camper to leave camp, or any FFD & DOC function, for any reason, I will make provisions to bring the camper home. I agree to notify FFD & DOC of any changes that need to be made in this application before a camp session. I understand FFD & DOC accepts applications on a first come first serve basis, and applications and physical forms must be submitted annually. I understand incomplete application may result in loss of application priority. Each family will receive a number when they arrive at the night/day of camp. Numbers at check-in are given on a first-come, first-serve basis as campers arrive. No numbers will be given in advance. In fairness to all families, we will not hold places or distribute numbers prior to arrival time. Please be prompt with pick-up on Sunday morning. Staff members are unable to provide after-hour care. I understand I may be subject to a late pickup fee of $25 per hour. I hereby certify that to the best of my knowledge, all the information contained in this application is true and complete.
Initial *

Clear
My initials above indicate I have read, understand, and agree with each corresponding section of the release statement.
Consumer Name (Camper) *
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Print Name *
Page 14 of 16

Horseback Riding Acknowledgement of Risk and Acceptance of Responsibility & Release of Liability

Prospect Riding Center and Wolfe's Born to Ride LLC
I, parent/guardian name* (Parent/Guardian), hereby acknowledge that I have voluntarily applied to engage camper name* (camper) in the activity of horseback riding with the Foundation for Dreams, Inc and Dream Oaks Camp, Prospect Riding Center and Wolfe's Born to Ride LLC. I understand that the activity of horseback riding involves numerous risks, including loss of control, collisions, and obstacles, whether they are obvious or not obvious. I further understand that an animal, irrespective of its training and usual past behavior and characteristics, may act or react unexpectedly or unpredictable at times, and I also assume such risks. I understand that my camper may encounter variations in terrain, which may result in injury or damages. I acknowledge that these are my responsibility, and I assume the risk for these hazards, including breaks, growth, debris, rocks, cliffs, and other hazardous surfaces or subsurface conditions and obstacles, whether they are obvious or not apparent, man-made or natural. I understand that animals are unpredictable and that the risk of injury is inherent to the activity.

I agree to assume all risk of injury or death associated with horseback riding, whatever the cause. I understand that the equipment being used at Foundation for Dreams, Inc, Dream Oaks Camp, Prospect Riding and Wolfe's Born to Ride, LLC is maintained to the best of their abilities. I agree to assume all risk of injury or death caused by equipment failure, whatever the cause. As consideration for being permitted by The Foundation for Dreams, Inc, Dream Oaks Camp, Prospect Riding and Wolfe's Born to Ride, LLC to engage in the activity of horseback riding, I do hereby waive any claim, and release The Foundation for Dreams, Inc, Dream Oaks Camp, Prospect Riding and Wolfe's Born to Ride, LLC and all owners, officers and members, affiliated organizations, horse and landowners, agents and or employees for any injury or death caused by, or resulting from my camper's participation in the activity of horseback riding.

This contract shall be legally binding upon my estate, assigns, my personal representatives, and self. Pursuant to Florida Statute §773.04, the following warning applies: UNDER FLORIDA STATE LAW, AN EQUINE ACTIVITY SPONSOR OR EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO, OR THE DEATH OF A PARTICIPANT IN
EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES. I have carefully read this agreement and fully understand the concerns. I am aware that I am releasing certain legal rights that I otherwise may have, and I enter into this contract on behalf of the camper of my own free will. THIS IS A RELEASE OF LIABILITY. By signing this release, you agree to the terms outlined in this agreement.
Consumer Name (Camper) *
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Print Name *
Page 15 of 16

Scholarship Application Form
- The Foundation for Dreams will never turn a family away for the inability to pay. We do offer full and partial scholarships to families based on financial needs.
- We use a sliding scale combining the number of household members in relation to household income. We may also take special circumstances into consideration.
- All information provided is kept confidential.
- Questions: Contact our office at 941-746-5659
REQUIRED INFORMATION

(Please fill out all sections below in detail)
Camper Name:
Date:

Month Day Year
Date
AMOUNT OF SCHOLARSHIP FUNDING YOU ARE REQUESTING: $
County of residence:
Zip Code (required):
The number of people in household:
Annual HOUSEHOLD income:
REASON FOR SCHOLARSHIP REQUEST (Please use the space to explain any hardships or extenuating circumstances that you would like us to consider.) *
INCOME VERIFICATION

(Please check appropriate box below.)
NEW SCHOLARSHIP APPLICATION

Acceptable Proof of your HOUSEHOLD income is attached
Attached proof of HOUSEHOLD income:

Most recent Income Tax Return W2 for all earners SSI award letter Foster care income statement
File Upload

Cancel of
Page 16 of 16

PHYSICAL AND MEDICAL ADMINISTRATION FORM A-1
Medications will not be administered, unless they are approved by your health care provider (FORM A-2) and, if necessary, any changes in medication information after submission of this form needs to be documented using (FORM B).
It’s important that you follow the guidelines exactly.

Failure to supply medications with original containers as requested may result in your child not being admitted to camp. All campers, regardless of age or level of independence, will have medications administered by the Camp Nurse.
PRESCRIPTION MEDICATION
- All prescription medications require permission for administration by your health care provider.
- All products must be in their original container or pre-poured in pill dispenser with the day and time to be given and original bottles with 1-3 extra pills of each medication must also be provided.
***Click here to view an instructional video on how to pre-pour medication for camp
NON-PRESCRIPTION MEDICATION / SUPPLEMENTS / HERBS
- All non-prescription medications require permission for administration by your health care provider.
- All products must be in their original container or pre-poured in pill dispenser with the day and time to be given and original bottles with 1-3 extra pills of each medication must also be provided.
ADDITIONAL REQUIREMENTS

Medication Administration Changes–FORM B
- Form B will need to be submitted if there are any changes in medication
  between the time the health care provider originally signs this document (FORM A-2) and the start of the camp session.
- If medications that have changed are essential for your child’s health, we are not permitted to admit them to camp until proper documentation is provided.
PLEASE PROVIDE THE FOLLOWING TO THE NURSE AT CHECK-IN:
- Medications in their original containers, in a Ziploc bag labeled with the camper’s first and last name
OR
- Medications pre-poured in pill dispenser with day and time to be
  given and the original bottles with 1-3 extra pills.
- Prescription medication bottles must have the prescription label on them and match the doctor's orders on the medical forms.
- Please bring Form B completed, as needed for any recent medication changes
PARENT / LEGAL GUARDIAN PERMISSION TO OBTAIN MEDICAL TREATMENT

The undersigned hereby consents to the Participant receiving medical treatment that may be deemed advisable in the event of injury, accident, and/or illness while attending Dream Oaks Camp, and the undersigned further assumes liability for all medical expenses and all other damages and expenses resulting from any injury, accident and/or illness in connection with a Foundation for Dreams or Dream Oaks Camp sponsored activity and/or event.
Name of Parent / Legal Guardian *

First Name Last Name
Parent / Legal Guardian Signature *

Clear
Date *

Month Day Year
Date
Parent / Legal Guardian Phone Number *
Please enter a valid phone number.
Parent / Legal Guardian Phone Number
Please enter a valid phone number.
Should be Empty:

ANNUAL ENROLLMENT REGISTRATION PACKET

ANNUAL REGISTRATION CHECKLIST

CAMPER INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

CHECK PROCEDURE & RELEASE

MEDICAL / HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

MEDICAL/HEALTH INFORMATION

Behavioral Information

Activities of Daily Living

Activities of Daily Living

Activities of Daily Living

Activities of Daily Living

Program Questionnaire

Program Intake Form

Participant Release Statement

Horseback Riding Acknowledgement of Risk and Acceptance of Responsibility & Release of Liability

Scholarship Application Form

REQUIRED INFORMATION

INCOME VERIFICATION

PHYSICAL AND MEDICAL ADMINISTRATION FORM A-1