Quality of Life Application

Please fill out the form in it's entirety. If you have any questions or need help filling out the form please call Helen Pino at hpino@cthf.net

Program which your child would like to participate

Sports Chair (Wheelchair) Basketball

Adaptive Cycling

Virtual Camp

Camp Adventure

Child's Name

Age

Date of Birth

Phone

Street Address

Second Address

City

State

Zip Code

Gender

Grade Level

Name of School

Primary Diagnosis

When was the participants last appointment with Carrie Tingley Hospital

Ethnicity

Hispanic

Non Hispanic

Number in Household:

Household income:

First Parent/Guardian Name:

Phone

Street Address

Second Address

City

State

Zip Code

Second Parent/Guardian Name:

Phone

Is address different from above?

EMERGENCY CONTACT INFORMATION: (if parent/guardian cannot be reached): Identification will be required if picking up/transporting participant

Emergency Contact Name

Phone

Relationship to Participant

Authorized to Pick up/transport:

Emergency Contact Name

Phone

Relationship to Participant

Authorized to Pick up/transport:

INSURANCE – Please enter your child’s insurance information in the sections that follows.

If your child is not currently covered by medical insurance, you are required to sign release of liability for campers without medical insurance.

Name of Insurance Carrier:

Policy #:

Policy Holder:

Group #:

Insurance Phone #:

Upload Insurance Card

In the event of illness or injury, a reasonable effort will be made to contact you to obtain consent in advance of medical services being given to your child. If we are unable to contact you, CTHF Executive Director and/or CTHF Staff Member will consent to such services for your child by acting on your behalf, based on the written advance authorization below.

Authorization for Medical Services

I, the parent/guardian of Program Participant have read the above statement regarding the authorization of emergency medical services in the event I cannot be reached. I designate CTHF Executive Director and/or CTHF Staff Member to authorize medical attention, hospitalization, and surgery as may be required in an emergency because of illness or injuries sustained by my child while participating in any of the Quality of Life programs. I hereby assume financial responsibility for hospitalization, medical attention, and surgery provided.

Medical Concerns:

Please List all Medications (prescriptions/OTC)

CTHF will not administer medications of any kind – No Exceptions

Does your child have any of the following:

Allergies

Visual Impairment

Hearing Impairments

Learning Disabilities

Cognitively (Academically) Functions Below Peer Level:

What level?

Immunizations Current?

Does your child use any special equipment?