February 2016
Over the weekend of May 13, 14 and 15th Family Support Network and the Orange County
community will be hosting its 23rd Annual Camp TLC event! TLC stands for Teaching, Loving, Care.
Camp TLC is a wonderful family experience accomplished through the blending of inspirational
speakers and educational workshops led by parents, nationally renowned speakers, and
experienced local professionals. The camp is held in a beautiful country setting at the Irvine Ranch
Outdoor Education Center in the foothills of Orange County. This setting creates a feeling of
camaraderie among the participating families. Provided on site will be a complete camp staff of
doctors, nurses and childcare providers.
This is an opportunity your entire family will not want to miss! To be eligible for camp your child with
special needs must be:
Enclosed you will find a camp application, brochure and a medical release form (to be completed
for any children who have medical concerns, such as currently taking medications, requiring
supportive equipment, has a tracheotomy, etc). These forms should be completed as soon as
possible, prior to the April 1 deadline, and returned to Family Support Network.
Due to the availability of accommodations, we can only sponsor 40 families. Therefore, applications
will be considered on a first-come-first-serve basis. The enclosed brochure describes this unique
weekend experience. To ensure that your family receives the earliest consideration possible, please
return this application immediately, along with the $40.00 application fee. You may request a
waiver of the fee if your family is experiencing extreme financial hardship. The Medical Release
Form must be returned by April 1. All forms can be sent to Family Support Network, ATTN: Camp
TLC, at the above address.
Remember, only 40 families can attend. Applications should be forwarded as soon as possible and
must be received no later than
April 1, 2016.
Families who have participated in a previous camp
are not eligible to participate in this year’s camp.
We look forward to a very positive and rewarding Camp TLC event this year. If you have any
questions, please contact Family Support Network at (714) 447-3301.
Sincerely,
THE CAMP TLC COMMITTEE
Six months of age by May 31st, 2016
Under the age of five, except for those children whose fifth birthday falls in the month of
May.
Experiencing a significant long-term medical condition, or is receiving special education
ser-vices from a school district program
OR
Regional Center
Family Support Network
Special Services for Special Families
1015 S Placentia Ave Fullerton, CA 92831 Web: www.familysupportnetworkca.org Phone: (714) 447-3301 Fax: (714) 447-3302 Email: [email protected]
Family Support Network 1015 S Placentia Ave Fullerton, CA 92831 Phone: (714) 447-3301 Fax: (714) 447-3302 Email: [email protected] www.familysupportnetworkca.org
For Office Use Only
# Received_____________ Nursing________________ Room #________________ # in
CAMP TLC APPLICATION
May 13, 14 and 15, 2016
*Camp is on a first-come-first-serve basis. Return this application form as soon as possible.
Name:___________________________________________________________________________________________
Last First Spouse
Address:__________________________________________________________________________________________ Street Apt #
_________________________________________________________________________________________________
City State Zip Code
Phone Numbers: Day____________________ Night____________________ # of children attending_____________ Will your child(ren) require nursing care? Yes No
Do YOU have any medical concerns we need to be aware of? If yes, please explain:_____________________________ _________________________________________________________________________________________________ Name of agency that referred you to Camp TLC:__________________________________________________________
MEDICAL INFORMATION FOR CHILD WITH SPECIAL NEEDS (CHILD #1)
Child’s Name:_____________________________________________ Date of Birth:______________________________________ Emergency Contact (Name/Number):_____________________________________________________________________________ Child’s Doctor (Name/Number):_________________________________________________________________________________ Disability:__________________________________________ Medications:______________________________________________ Special medical conditions:_____________________________________________________________________________________ Special medical equipment you will bring:_________________________________________________________________________ Regional Center client? Yes No
MEDICAL INFORMATION FOR CHILD WITH SPECIAL NEEDS (CHILD #2)
Child’s Name:_____________________________________________ Date of Birth:______________________________________ Emergency Contact (Name/Number):_____________________________________________________________________________ Child’s Doctor (Name/Number):_________________________________________________________________________________ Disability:__________________________________________ Medications:______________________________________________ Special medical conditions:_____________________________________________________________________________________ Special medical equipment you will bring:_________________________________________________________________________ Regional Center client? Yes No
Camp TLC Application—Continued
Others Attending (Siblings):
Name:____________________________ Age:____________ Medical Conditions: Yes No Meds:______________________ Name:____________________________ Age:____________ Medical Conditions: Yes No Meds:______________________ Name:____________________________ Age:____________ Medical Conditions: Yes No Meds:______________________ Name:____________________________ Age:____________ Medical Conditions: Yes No Meds:______________________ Are any of these children receiving services?_______________________________________________________________________
To be eligible for camp, your child with special needs must be at least 6 months by May 31st and
under the age of 5, except for those whose 5th birthday falls in the month of May.
PLEASE NOTE THE FOLLOWING:
Camp IS NOT a resort hotel with all the amenities. It is an outdoor camp in a wilderness area. You may be required to use communal showers and restroom facilities, somewhat like a college dorm. Keep in mind that the area is dusty and hilly in the foothills of Orange County. Please keep the medical needs of your children in mind when you decide to attend this seminar. Child care will be provided in a group setting. Formulas and medications will not be provided at camp, but secure refrigerated storage facilities are available for your child’s formula and medications.
The camp will not provide any special equipment. All equipment you bring with you must be marked with your name, and you must assume all responsibility for the safety and condition of your equipment.
Physician Release is required for your child with special needs to attend camp if your child will be receiving nursing care/supervision, prescribed medication or special equipment.
Family Support Network cannot provide transportation. Before submitting this application, please make sure your family has a ride to and from camp.
There is no alcohol allowed on the conference grounds.
This camp is limited to immediate family members only.
Please include with your application a $40.00 non-refundable check (reservation fee) payable to
Family Support Network. (If requested, this fee may be waived in case of extreme financial hardship)
Mail or Fax Completed Application Packet to: Family Support N etwork
ATTN : Camp TLC 1015 S Placentia Ave
Fullerton, CA 92831 Fax: (714) 447-3302
*
Applications must be received before: April 1, 2016
*As a participant in this seminar, you are responsible for the health, welfare and safety of yourself and your family.
I hereby release Family Support Network and volunteers from all liability connected with the seminar, and
agree to hold them harmless from any damage or injury that may occur as a result of participating in this
activity.
____________________________________________
________________________________________
Signature
Date
Camp TLC Application—Continued
Please check all the topics you would be interested in getting more information about:
IHSS (In-Home Support Services)
SSI (Supplemental Security Income)
Medi-Cal Waiver
Therapy Coverage
Inclusion/Mainstreaming
IEP (Individualized Education Plan)
Medical Issues
Regional Center of Orange County
Medical Issues
Support Groups
All of the above
Other:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Family Support Network 1015 S Placentia Ave Fullerton, CA 92831 Phone: (714) 447-3301 Fax: (714) 447-3302 Email: [email protected] www.familysupportnetworkca.org
For Office Use Only Child’s age
Special equipment Notes
CAMP TLC
MEDICAL RELEASE/DESCARGO MÉDICO
(
For child with medical concerns only/
Para el niño con necesidades especiales solamente)
Medical Information (Información médica)
__________________________________________________________________________________________________ Name (Last, First)/Nombre (Apellido, Primer) Parent/Guardian Name (Nombre—Padre) __________________________________________________________________________________________________ Address (Dirección) City (Ciudad) Zip Code (Codigo Postal) __________________________________________________________________________________________________ Phone, including area code Child’s DOB/Age Male/Female
(Teléfono y edad) (Fecha de nacimiento) (Hombre/Mujer) ALLERGIES (Please list)/ALERGIAS (Favor de listar):
__________________________________________________________________________________________________ __________________________________________________________________________________________________
This person is in satisfactory condition to attend Camp TLC and may engage in all usual activities except
as noted:__________________________________________________________________________________________ __________________________________________________________________________________________________
Licensed Physician’s Name:____________________________________________________________________________ Licensed Physician’s Signature:_______________________________________________ Date:______________________ Physician’s Address:__________________________________________________________________________________ Phone:___________________________________________
Signature of Parent/Guardian:_______________________________________________ Date:______________________
FOLLOWING PORTION TO BE COMPLETED BY CHILD’S PHYSICIAN
Please return signed Medical Release Form by April 1st, 2016
Favor de devolver esta Forma de Descarga Médica firmada por usted y el médico de su niño antes del 1 de Abril Mail or Fax to:
Family Support Network ATTN: Camp TLC 1015 S Placentia Ave
Fullerton, CA 92831 Fax: (714) 447-3302