Fw: Deliver the Dream Retreat application

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----- Forwarded Message ----- To: Sent: Tuesday, November 20, 2012 9:04 AM Subject: Deliver the Dream Retreat application

Family Retreat 2013 Application Thank you for your interest in Deliver the Dream, a free weekend retreat for families who have a child or parent with a serious illness or crisis. Please read further for information on our program and the application process. Eligibility: ï’

Families must fit the illness or crisis criteria listed below. ï’

Families must have children between the ages of 0-18 years old living in the household. ï’

Family members attending must be living in the household of the applicant. ï’

Families must

commit to attending the entire weekend from Friday at 11:30am until Sunday at 1:30pm. ï’

Families must participate in all scheduled activities. ï’

Families must be able to provide their own transportation to and from the venue. ï’

Families can not attend more than once. The following forms must be completed and returned before your application can be processed: ï’

Completed application (pages 3-6) ï’

Applicant Medical History & Health Examination (pages 7-8 )

*portion to be filled out by a physician* ï’

Family Medical & Emergency Information (pages 9-11 ) ï’

Releases for Publication, Travel, Participation & Claims (page 12) Group Served Date Location Application Deadline Families who have a child with a craniofacial condition February 8-10 FFA Leadership Training Center Haines City, Florida January 8th Families who have a child with spina bifida March 8-10 FFA Leadership Training Center Haines City, Florida February 8th Families who have a child with an autism spectrum disorder or a related disability April 19-21 Cerveny Conference Center Live Oak, Florida March 19th Families who have a child with a blood disorder May 17-19 FFA Leadership Training Center Haines City, Florida April 17th Families who have experienced the death of a loved one June 28-30 Duncan Conference Center Delray Beach, Florida May 28th Families who have a child with cancer July 26-28 Duncan Conference Center Delray Beach, Florida June 26th Families who have a parent with cancer August 16-18 FFA Leadership Training Center Haines City, Florida July 16th Families who have a child with down syndrome September 20-22 The Fountains Orlando, Florida August 20th Families who have a child with cerebral palsy October 11-13 FFA Leadership Training Center Haines City, Florida September 11th Families who have a parent with multiple sclerosis November 15-17 FFA Leadership Training Center Haines City, Florida October 15th Frequently Asked Questions Once your application is completed, please mail or fax it to: Deliver the Dream · 3223 NW 10th

Terrace, Suite 602 · Ft. Lauderdale, FL 33309 Fax: Questions: 1.888.OUR DREAM 2 When will I know if my family is selected to attend the retreat? You will be notified by Deliver the Dream of your family’s application status 2-3 days after the deadline date via email or phone. Space is limited for up to 15 families so please make sure to turn your application in on time. Late applications will still be reviewed but will result in a lower priority status.

A completed application does not guarantee acceptance. What happens on a retreat? Deliver the Dream provides structured therapeutic family-centered activities for up to 15 families that offer respite, relaxation, and recreation for those who are experiencing similar challenges. A Deliver the Dream weekend will give you and your family a new sense of self and enhanced coping skills. Are there age specific activities? Yes. Most of the activities include the entire family, but there are times when your family will be split up into groups based on age and illness or crisis. For the tots (ages 6-weeks to 1st

grade), “Kids Korner†will be available during those time periods when parents are participating in structured activities. Youth (2nd

grade- 12), teens (ages 13-18) and adults will participate in separate age appropriate selected activities too. What types of activities will we be doing? You and your family will be participating in structured activities such as assorted recreational indoor and outdoor activities, discussion groups, interactive games, creative workshops, team building exercises, and more! If you have ever been to camp, we do a lot of the same activities. Ample time is also provided for relaxation, spending time with family members and meeting new supportive friends. Where is the retreat located? Each retreat is offered at our selected venues which are miles away from the hustle and bustle of the crowded city. Each venue is unique but all are located in rustic surroundings where its natural beauty creates an atmosphere perfect for a fun-filled weekend retreat. Where do we stay? Families will stay in hotel-like rooms with two double beds and a private bath (the number of rooms are based on the size of a family). Linens and towels are provided. Rooms are not equipped with a TV or telephone but there is wifi located in main buildings. Breakfast, lunch & dinner will be prepared by the food service professionals and is served buffet style in the main dining hall. What does the retreat cost? Nothing! Thankfully, due to the generosity of our sponsors, Deliver the Dream will cover

ALL lodging, activities, & group meal expenses. What happens if someone from my family is not feeling well on the retreat? There is a medical professional on the retreat, who is available 24/7 to administer first aid for minor bumps and bruises. In the event of an emergency, they will assist in getting your family member to a local hospital. Are there any restrictions on the retreat? Yes, pets are not allowed and this is an alcohol and drug free weekend. Please remember you must attend and participate in all retreat activities the entire weekend (Friday at 11:30am until Sunday at 1:30pm). Still not sure about applying? Check out our website! There are plenty of testimonials plus a great video that shows you how much fun you will have on a retreat (www.DelivertheDream.org). 3 Family Application Please print clearly. Black/blue ink only. What retreat are you applying for

(date only):__________________________________________________________ *Applicants First & Last Name:_____________________________________________________________ M or F Parent or child with the serious illness or crisis Relationship to the family:________________________________ Date of Birth:_________________ Age:_______ Diagnosis:________________________________________________________ Date of Diagnosis:________________ Estimated # of hospital visits per year:_________ *Cause of Death:_______________________________________ *How many month or years has it been since your loved one died:_______________________________________ Please tell us a little about the applicant:______________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please check any behavioral or emotional conditions that the applicant has/had been diagnosed with: ( )ADD/ADHD ( )Anxiety ( )Depression ( ) OCD ( )Other:_______________________________________ __________________________________________________________________________________________________ *NOTE: If you are applying for a bereavement weekend please list the deceased as the applicant* 4 Please list the other family members who will attend the retreat: ______________________________________________

M or F _______________________ _____________ _______ First & Last Name Relationship DOB Age ______________________________________________

M or F _______________________ _____________ _______ First & Last Name Relationship DOB Age ______________________________________________

M or F _______________________ _____________ _______ First & Last Name Relationship DOB Age ______________________________________________

M or F _______________________ _____________ _______ First & Last Name Relationship DOB Age ______________________________________________

M or F _______________________ _____________ _______ First & Last Name Relationship DOB Age ______________________________________________

M or F _______________________ _____________ _______ First & Last Name Relationship DOB Age Home Address _____________________________________________________ Apt/Suite __________________ City ___________________________________ State _________ Zip ___________________________ Phone Numbers ____________________________ ________________________ _______________________ Please include area codes cell home work E-mail _________________________________ Preferred method of communication:

cell home work email mail You may circle more than one Other: List languages spoken by your family members

(please note that all sessions are in English): ( )English ( )Spanish ( )French ( )Other_________________________________________________________ If a family member does not understand English please list their name(s) and language spoken: __________________________________________________________________________________________________ Please check all special equipment that your family will bring to the retreat: ( ) N/A ( )Cane ( )Crib ( )Crutches ( )Power Wheelchair ( ) Wheelchair ( ) ( )Other_____________________ Please state who will be utilizing the items checked above:____________________________________________ Will that person need a handicapped accessible room? ( )Yes ( )No Does your family require the use of a refrigerator for medications or baby formula? ( )Yes ( )No Please note: Parents must bring baby formula, diapers and baby food for all infants Has anyone in your family ever attended a sleep away or day camp? ( )Yes ( )No If yes, please explain. __________________________________________________________________________________________________ Have you ever applied for a Deliver the Dream retreat? ( )Yes ( )No If yes, when:_______________________ Has your family ever received a wish or dream from another organization? ( )Yes ( )No If yes, from what organization?_____________________________________________________________________________________ Who referred you to our program (organization/person)?_______________________________________________ 5 Please answer the following questions: Tell us about your family. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6 How do you feel this retreat might be beneficial for your family?_________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 7 Applicant Medical History and Health Examination If applying for a bereavement weekend please skip to page 9.

The following information MUST be completed by the parent or adult applicant (There is a section to be filled out by a physician medically clearing the applicant for the weekend). This will provide the Deliver the Dream medical professional with appropriate information on the applicant’s specific needs. Please notify us if there are any changes to the health status of the applicant prior to the weekend. ____________________________________ _______________________________ _________________ ( ) Female ( ) Male Last First Middle _____________________ ________ ________________ ___________________ Date of Birth Age Height Weight Insurance Information Name of Company: ____________________________________________ Phone #:____________________________________ Member ID: ___________________________________________ Group #:_________________________________ Allergies Does the participant have allergies to any food, medicines or any substance? ( ) Yes or ( ) No If yes, please list. Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:____________________________________________ Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:____________________________________________ Medications

_______ Check here for no medications Medications Reason Amount How Often 8 Food Restrictions

_______ Check here for no food restrictions ( ) Does not eat red meat ( ) Does not eat pork ( ) Does not eat eggs ( ) Does not eat poultry ( ) Does not eat seafood ( ) Does not eat dairy products ( ) Gluten Free ( ) Other

(please be specific) ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Provide additional information regarding the applicant’s behavior. Describing their physical, emotional, or mental health which Deliver the Dream staff should be aware of. ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Licensed Medical Professional’s Health Care Recommendations *This portion is to be completed and signed by a licensed medical professional* I hereby attest that I am the treating physician for _______________________________________ and in my opinion, the named applicant

( )IS or ( )IS NOT able to participate in activities offered during the Deliver the Dream Retreat. The applicant is under the care of a physician for the following condition(s): ____________________________________________________________________________________________________________ Medications and or treatment to be administered by parents/guardians during the Retreat Weekend: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Any medically prescribed meal plan or dietary restrictions:

_____________________________________________________________ Description of any limitations or restrictions on weekend activities:______________________________________________________ ____________________________________________________________________________________________________________ Other: _____________________________________________________________________________________________________ _________________________________________________

________________________________________________ ________________ Physician Printed Name Physician Signature Date ______________________________________ _________________________________________ Office Number Pager (in case of emergency)

8 9 Family Medical and Emergency Information Please do not add the applicant to this form. This form

is for the other family members attending the retreat. All of this information is keep confidential and will only be shared with Deliver the Dream’s medical professional. It is extremely important that you fill this form our in its entirety. Please print clearly and list each family member individually. 1. First and Last Name: _______________________________________________________ Does the participant have allergies to any food, medicines or any substance? YES or NO If yes, please list. Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:____________________________________________ Does the participant have any food restrictions?(vegetarian, no meat, gluten free, etc.) YES or NO If yes, please list. ________________________________________________________________________________________________________________________ Does the participant have any health conditions that may limit their participation? YES or NO If yes, please explain. _____________________________________________________________________________________________________________ Please list all current over the counter or prescription medications. _____ Check here for no medications 2. First and Last Name: _______________________________________________________ Does the participant have allergies to any food, medicines or any substance? YES or NO If yes, please list. Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:____________________________________________ Does the participant have any food restrictions?(vegetarian, no meat, gluten free, etc.) YES or NO If yes, please list. ________________________________________________________________________________________________________________________ Does the participant have any health conditions that may limit their participation? YES or NO If yes, please explain. _____________________________________________________________________________________________________________ Please list all current over the counter or prescription medications. _____ Check here for no medications Medications Amount How Often Medications Amount How Often 10 3. First and Last Name: _______________________________________________________ Does the participant have allergies to any food, medicines or any substance? YES or NO If yes, please list. Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:____________________________________________ Does the participant have any food restrictions?(vegetarian, no meat, gluten free, etc.) YES or NO If yes, please list. ________________________________________________________________________________________________________________________ Does the participant have any health conditions that may limit their participation? YES or NO If yes, please explain. _____________________________________________________________________________________________________________ Please list all current over the counter or prescription medications. _____ Check here for no medications 4. First and Last Name: _______________________________________________________ Does the participant have allergies to any food, medicines or any substance? YES or NO If yes, please list. Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:____________________________________________ Does the participant have any food restrictions?(vegetarian, no meat, gluten free, etc.) YES or NO If yes, please list. ________________________________________________________________________________________________________________________ Does the participant have any health conditions that may limit their participation? YES or NO If yes, please explain. _____________________________________________________________________________________________________________ Please list all current over the counter or prescription medications. _____ Check here for no medications Medications Amount How Often Medications Amount How Often 11 5. First and Last Name: _______________________________________________________ Does the participant have allergies to any food, medicines or any substance? YES or NO If yes, please list. Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:___________________________________________ Does the participant have any food restrictions?(vegetarian, no meat, gluten free, etc.) YES or NO If yes, please list. ________________________________________________________________________________________________________________________ Does the participant have any health conditions that may limit their participation? YES or NO If yes, please explain. ____________________________________________________________________________________________________________ Please list all current over the counter or prescription medications. _____ Check here for no medications 6. First and Last Name: _______________________________________________________ Does the participant have allergies to any food, medicines or any substance? YES or NO If yes, please list. Allergies: _________________________________________ Reaction:___________________________________________ Allergies: _________________________________________ Reaction:___________________________________________ Does the participant have any food restrictions?(vegetarian, no meat, gluten free, etc.) YES or NO If yes, please list. ________________________________________________________________________________________________________________________ Does the participant have any health conditions that may limit their participation? YES or NO If yes, please explain. ____________________________________________________________________________________________________________ Please list all current over the counter or prescription medications. _____ Check here for no medications Emergency Contact

(must be someone not attending the retreat) ________________________________________ _______________________________ ____________________________ Name Relationship Phone Number Medications Amount How Often Medications Amount How Often Permission to Administer Treatment The information contained in these medical forms is correct and complete to the best of my knowledge. I grant permission for the above-named

guests herein to engage in Deliver the Dream retreat weekend activities with exception to those noted on these forms and agree to abide by any restrictions placed on me or my family. I hereby give permission to Deliver the Dream on-site professional health staff to provide routine health care,

administer prescribed medications (if necessary), and seek emergency medical treatment. I agree to the release of any records necessary for insurance

purposes. I give permission to Deliver the Dream to arrange necessary health-related transportation for me or my family. In the event I cannot be reached

during an emergency, I hereby give permission to the appropriate medical personnel selected by Deliver the Dream to secure and administer treatment,

including hospitalization, for the above-named guests. If necessary, a copy of this completed form may be used for any trips away from the Deliver the

Dream retreat weekend facility that may be offered as part of the overall program. _________________________________________________ ____________________________________________ __________________________ Parent/Legal Guardian Name Parent/Legal Guardian Signature Date

11 12 Releases for Publication, Travel, Participation and Claims Please list every family member attending the retreat below. First and last names please. 1. __________________________________ 5. ______________________________________ 2. __________________________________ 6. ______________________________________ 3. __________________________________ 7. ______________________________________ 4. __________________________________ 8. ______________________________________ Release for Publication

(please initial yes or no below) During the course of the Deliver the Dream experience, there will be occasions when your family members may be photographed and/or videotaped by staff, sponsors, corporate representatives, media and others. We request permission for you and your family member’s participation. By initialing below, parents and/or guardians may choose to grant or deny Deliver the Dream, Inc. permission to use photographs or videotapes of the above-named family members, alone or in groups, in newspaper articles, newsletters, Web-site, brochures, special fundraising activities, scrapbook, videos and photo albums for use in public understanding and support of the Deliver the Dream program. By granting permission below, you hereby release and hold harmless Deliver the Dream, Inc. from any claims, judgments or demands which may arise from the use of the above referenced photographs and/or videotapes. ________ “YES, I/we give permission for the above-named _______ “NO, I/we deny consent for the above-named Initial

guests to be photographed and/or

Initial

guests to be photographed and/or videotaped for publicationâ€. videotaped for publicationâ€. Permission to Participate, Travel and Release of Claims

(please fill out below) I/We, on behalf of myself or ourselves, and as parent(s)/guardian(s) of the _______________________

family minor children, hereby give permission for the above-named family members (hereinafter “the Familyâ€) to travel to _________________________________________

(retreat location) on ___________________________________ (date), as participants in the Deliver the Dream Retreat Weekend Program (hereinafter “the Retreat Weekendâ€). I/We understand that “the Family†will travel by car to “the Retreat Weekend†which will take place from ______________________________(date). I/We understand that while at “the Weekendâ€, depending on the venue, “the Family†may be offered *physical activities including, but not limited to rock wall climbing, swimming, boating, arts & crafts, tennis and basketball. (*Please note activities are subject to change depending upon the venue). In consideration of participation in “the Retreat Weekendâ€, I/we, for myself/ourselves, heirs, executors, and administrators, hereby personally and on behalf of “the Familyâ€, release, indemnify, save and hold harmless, acquit, forever discharge and waive any claims or causes of action which “the Family†or I/we may now or hereafter have against Deliver the Dream, Inc. other participating agencies, all corporate sponsors and collaborators, and their respective subsidiaries and affiliates and any and all of their officers, directors, trustees, agents, servants, associates, employees, representatives, shareholders, beneficiaries, successors, and assigns, of all liabilities, claims, actions, damages, costs, or expenses which they or I/we may now or hereafter have arising out of or in any way connected with participation by “the Family†in Deliver the Dream, including, but not limited to, travel to or from “the Retreat Weekend†and injuries which may be suffered before, during, or after “the Retreat Weekendâ€. I/we understand that this waiver includes any claims based on negligence, action, or inaction of the above parties. I/we understand that we are assuming the risk for any activities we participate. _________________________________________ ________________________________________ __________________ Parent/Legal Guardian Name Parent/Legal Guardian Signature Date OR Katz

Assistant Director

Respite Program

Broward Children's Center

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fax Confidentiality Note: