Partners and Pals 2018 Waiting List
The Arc of Tri-Cities has had an overwhelmingly positive response for this year's summer camps. We have almost filled all camps to full capacity, a month before camp is due to start, which has never before happened to us.
If you are interested in attending camp and would like to register to attend camp, or have your child placed on a waiting list, please fill out the below application.

PLEASE NOTE:
All camps are now full, and all further applications will be placed on a waiting list.

Email address *
I have immediate funding available for Partners N Pals.
The Arc of Tri-Cities has scholarship funds available for families that need it. Do you need scholarship funds to help your child attend camp?
Camper Information
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Gender *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Name of Apartment, Mobile Home Park, or Fascility
Your answer
School *
Your answer
Home Phone *
Your answer
T-Shirt Size *
Home Language *
Your answer
Camper Ethnicity
Parent or Guardian Information
First Name *
Your answer
Last Name *
Your answer
Cell Phone Number *
Your answer
Home Phone Number *
Your answer
Address *
Your answer
Apartment # (If Applicable)
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Employer *
Your answer
Email Address *
Your answer
Emergency Contact Information
First Name *
Your answer
Last Name *
Your answer
Cell Phone Number *
Your answer
Home Phone Number *
Your answer
Address
Your answer
Parent Survey
Why are you participating in Partners N Pals (Please check all that apply)
What community skills are you hoping your child will learn while participating in camp? (Please check all that apply)
How did you find out about Partners N Pals? *
Required
Health Information
My son/daughter is a *
What is the camper's disability? (If none, please write none) *
Your answer
Limitations? (If none, please write none) *
Your answer
Medications? (If none, please write none) *
Your answer
Allergies we should be aware of? (If none, please write none) *
Your answer
If an allergic reaction occurs please list steps to relieve reaction (If none, please write none) *
Your answer
Medical or daily needs we should be aware of? (If none, please write none) *
Your answer
Seizures? *
Date of last seizure
MM
/
DD
/
YYYY
The Arc of Tri-Cities seizure policy: If your child is in a seizure for over 2 minutes we will call 911 and then family. If you would like us to take different action please attach with this application a seizure plan. The Arc is not nurse delegated - which does not enable us to administer medications or VNS.
Other health concerns The Arc needs to be aware of? (If none, please write none) *
Your answer
Community Skills
How well does camper stay with a group? (Example: In a grocery store would the camper stay with you or do you have to do one of the following?) *
Communication *
Required
School Setting (Choose all that apply) *
Required
How well does the camper do at following directions? *
What does he/she do when happy?
Your answer
What does (s)he do when angry or frustrated? *
Your answer
Ideas on what to do when (s)he gets frustrated?
Your answer
Activities
Activities to be encouraged? (If none, please write none)
Your answer
Activities to be limited? (If none, please write none) *
Your answer
Ideas on what to do, or what helps, when (s)he gets angry/frustrated? *
Your answer
Personal Care
Does your child require help that requires physical touch assistance?
Campers Mobility *
Required
Eating (Please Note: Arc of Tri-Cities does not have nurse delegation) *
Toileting *
Dressing *
Activities
Activities to be encouraged? (If none, please write none) *
Your answer
Activities to be limited? (If none, please write none) *
Your answer
Swimming Assessment *
I acknowledge that swimsuits must have a liner in order for my child to be allowed to swim. *
Required
I acknowledge that if my child is incontinent, they must have a swim diaper or a plastic swim liner to wear under their swimsuit in order to be allowed to swim. *
Please describe your child's social skills/likes/dislikes *
Your answer
Transportation
I will need The Arc of Tri-Cities Transportation to pick up and drop off my child at my house. *
Pick up Address - Must be within same city as drop off (Please write out full address, with Zip code)
Your answer
Drop off Address - Must be within same city as pick up (Please write out full address, with Zip code)
Your answer
The Arc of Tri-Cities policy is to ensure someone is home before dropping the camper off, no matter what age they are. If your child is at least 12 years old and does not need someone home at drop off, please sign the following release.
My child is at least (12) years of age and I, the parent/guardian give The Arc of Tri-Cities my permission to LEAVE my child UNATTENDED at the residence listed in the drop off address above. *
My child is 8 years old OR older and does NOT need a booster seat. (If "No", please mark the below question) *
My child is 7 years old and is NOT 4 foot 9, and greater than 80lbs and will have to be transported in a cutaway vehicle. (Understanding that there is limited cutaway bus seats and if one is not available, my child will not be able to participate in camp.)
One on One Service
Please Note: The Arc of Tri-Cities One on One staff are not behavior experts, we ask
families to work with us and our staff and help us get to know your child to help make it a successful summer.
I would like to request one on one service for my child. (Understanding that this request is based on the capacity of the camp and The Arc of Tri-Cities ability to serve safely in a community setting) *
Payment Information
Do you want us to bill DDA respite dollars? *
(WAC 388-845-1615) Prohibits us from charging families additional fees. – Families paying with DDA dollars will be charged the regular cost and are not eligible for the reduced cost.
IF you would like to Bill DDA respite dollars, please list DDA Case Manager's name
Your answer
Kids Summer Bus Pass (Required): $25
The Arc of Tri-Cities has been fortunate to be able to access Ben Franklin Transit
vehicles to transport to and from home and within the camp. Our contract with Ben
Franklin Transit requires participants to have a bus pass to participate. We will be
purchasing bus passes at the beginning of June, July, and August. We will deliver bus
passes to your home by drivers on the first Monday of camp. One bus pass is good
for the whole summer.
Membership Reduces Cost: $50
How Do I get the Reduced Cost? Pay a one-time fee for Membership and Registration.
Registration Membership Fee is a one-time fee that includes a camp t-shirt that can be picked up on the last day of camp or 2 weeks after camp ends. This Fee Reduces weekly camp cost.
Camp Cost
Reduced (Membership) Group Cost: $160/week
Regular Group Cost: $185/week

Support 1 on 1 Reduced (Membership) Cost: $355/week
Support 1 on 1 Regular Cost: $375/week

Weeks *
Required
DDA Application (ONLY for families using DDA dollars)
For DDA to pay for your child's participation in The Arc of Tri-Cities
summer camp, you must pre-authorize them to do so. Funding will begin on the first day your child
starts camp.

STEP 1:
Tell your case-manager that you want to use your waiver service dollars towards The Arc of Tri-
Cities Summer Day Camp. Let them know the number of weeks and cost per week.

Step 2:
The Arc of Tri-Cities upon receiving this form will send it to your case manager.

Step 3:
The Arc must receive approval or required authorization before we can serve your child if using
DDA funding.

I have contacted DDA and the following weeks and are approved to be paid for by DDA.
I have contacted DDA and the following amount is approved to be paid for by DDA.
Your answer
Releases
The Arc of Tri-Cities has my permission, (both during and any time after camp), to use my likeness, name, voice, or words in eithertelevision, radio, film, newspapers, magazines, and other media, and in any form, for the purpose of advertising or communicating the purposes and activities of The Arc of Tri-Cities and/or applying for funds to support those purposes and activities. *
I hereby approve my child's application for membership in the Arc of Tri-Cities summer camp and consent to her/his being given a physical examination an/or emergency treatment by a physician or hospital in case of an accident. I also approve to him/her taking part in various activities at or with the Arc of Tri-Cities and will not hold The Arc of Tri-Cities and any of their staff or volunteers responsible for injury to my child, damage to her/his property, or lost or stolen property which might occur while participating in The Arc of Tri-Cities Partners 'N Pals camp activities. *
Required
By typing your full name here you are signing the camper release form and stating that everything on the application is correct and truthful to the extent of your knowledge *
Your answer
Additional Information that you would like to include but did not have space for above. (Optional)
Your answer
A copy of your responses will be emailed to the address you provided.
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