2017 Tulane Tidal Wave Transition Retreat- Initial Application
SPACE IS LIMITED....FIRST COME, FIRST SERVE!

DATES FOR Attendees: July 16 - 21, 2017 at Rosaryville Retreat Center, Ponchatoula, LA

STEPS TO REGISTER:

1. Please complete this attendee application and submit. AT THE END OF THIS APPLICATION BELOW, MAKE SURE TO PRESS SUBMIT. IF YOU DO NOT GET A THANK YOU, THEN YOUR FORM HAS NOT BEEN SUBMITTED. LOOK THROUGH THE FORM AGAIN AND ANSWER ANY QUESTIONS HIGHLIGHTED IN RED THAT ARE REQUIRED QUESTIONS. THEN PRESS SUBMIT AGAIN!

2. Once we receive your application, our medical committee will review and you will be notified when your application has been accepted to this years’ retreat.

3. Once you receive acceptance notification, you will be directed to complete additional required forms and information. Some forms will require signatures—SO PLEASE PLAN APPOINTMENTS ACCORDINGLY SO YOU CAN GET US FORMS ON TIME. Signatures will be required from:
• A doctor that gives medical clearance for your child to attend
• A therapist-- if your child has seen one in the past year


For any questions, please contact us at: TidalWaveRetreat@gmail.com

Attendee's Name *
Your answer
Preferred Name for Name Tag
Your answer
Date of Birth *
Your answer
Grade *
Please indicate current grade in school.
Your answer
Age attendee will be AT the retreat this summer *
Your answer
Sex *
Your answer
Parent/Guardian Name *
Your answer
Relationship to Attendee
Your answer
Street Address
Your answer
State
Your answer
City
Your answer
Zip Code
Your answer
Primary Phone *
Your answer
Secondary Phone
Your answer
Other Phone
Your answer
Email Address *
Note: All correspondence will be communicated via email, so please check your email for updates!
Your answer
Secondary Email Address
Please complete only if you want correspondence sent to this account.
Your answer
Emergency Contact Name *
Person to be contacted in case of emergency if parent/guardian cannot be reached.
Your answer
Relationship to Attendee
Your answer
Emergency Contact Primary Phone *
Your answer
Emergency Contact Secondary Phone
Your answer
Emergency Contact Other Phone
Your answer
Insurance Company Name *
Your answer
Phone *
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
County
Your answer
Policy Number
Your answer
Which bleeding disorder has your attendee been diagnosed with? *
What is the severity of your attendee's bleeding disorder? *
Your answer
Does the attendee have a target joint?
if YES, which one?
Your answer
Date of diagnosis of bleeding disorder *
Your answer
Diagnosing Physician's Name *
Your answer
Briefly describe history of bleeds *
Your answer
Dietary Restrictions *
Note: We will do our best to accommodate additional dietary restrictions other than GF. However, please only list those that are MEDICALLY necessary for your child
Your answer
Medication Allergies *
List all known. Describe reaction and management of the reaction.
Your answer
Food Allergies *
List all known. Describe reaction and management of the reaction.
Your answer
Other Allergies. *
List all known. Include insect stings, hay fever, asthma, etc. Describe reaction and management of the reaction.
Your answer
Does the attendee.... *
If yes, check the box.
Required
If you answered yes to any of the above, please explain.
Your answer
Which of the following has the attendee had? *
Please note: If you child has been exposed to any communicable disease, particularly chicken pox, measles, or mumps, 1 to 3 weeks prior to camp, please contact us as soon as possible.
Required
IMPORTANT REQUIREMENT-all attendees are REQUIRED to have proof of vaccinations. You must submit your child's immunization records once you are accepted to camp *
Please indicate below if your child is up to date on immunizations. YOU MUST SUBMIT YOUR UPDATED IMMUNIZATION VERIFICATION FORM. PLEASE UPLOAD AND EMAIL
Required
If no, please explain.
Your answer
Medication
The medical staff will store and administer any medications needed during the camp week. PLEASE SEND ALL MEDICATIONS TO CAMP WITH YOUR CHILD IN THEIR ORIGINAL CONTAINER WITH WRITTEN INSTRUCTIONS. It is expected that each family will supply in advance any routine medications needed. Specific instructions on how to send medications and the medication check-in process will be sent to you closer to camp.
Check one of the following boxes. *
List each medication name, dosage, and frequency.
Your answer
Name of Primary Care Physician *
Your answer
Primary Care Physician Phone Number *
Your answer
Name of Hematologist *
Your answer
Hematologist's Phone Number *
Your answer
Does your child use any special equipment such as a walker, crutches, wheelchair, or prosthesis? Please explain.
Your answer
Please list any physical restrictions or activity limitations (e.g., no swimming, no prolonged sun exposure, no competitive sports, sight or hearing loss, etc.).
Your answer
Is there anything we should know about your child that will make his/her adjustment smoother?
Your answer
Is your child able to function at his or her age level? Please describe.
Your answer
Describe any bedtime or sleep habits (e.g., sleeps with parent, toys, talks/walks/ in sleep, etc.).
Your answer
Does your child have any serious fears? Please describe.
Your answer
Please indicate any further information about your child's medical and/or emotional needs that you feel we should know. Please include if your child sees a psychiatrist or psychologist regularly.
Your answer
Attendee's T-shirt Size
If your child would like to share a bunk room with a friend, please list by name.
REQUESTS WILL ONLY BE CONSIDERED FOR ATTENDEES IN THE SAME AGE RANGE and will be assigned check-in. NOT GUARANTEED!
Your answer
Where did you hear about our retreat?
Your answer
Have you attended other bleeding disorder camps, retreats, conferences
If yes, please specify
Your answer
Do you plan to attend other summer camp programs this coming summer?
If yes, please list along with the dates
Your answer
If you would like to be considered for a limited number of scholarships, please provide an explanation of need.
Your answer
BE SURE TO CLICK SUBMIT!!!!!
MAKE SURE TO PRESS SUBMIT. THEN, IF YOU DO NOT GET A THANK YOU, YOUR FORM HAS NOT BEEN SUBMITTED. LOOK DOWN THE FORM AGAIN AND ANSWER ANY QUESTIONS HIGHLIGHTED IN RED THAT WERE REQUIRED QUESTIONS.
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