1. automotive and vehicles
2. campers and rvs

Applications will be date and time stamped upon arrival. Applications must have payment
with them to be considered completed. Camper spots will be allocated on a first come first
served basis. Once spots are filled you will be placed on a wait list. Camper letters
confirming spots will be sent out August 13, 2015 and cheques will be processed at this
time.
Camper Information/Application Package for September 17th-20th, 2015
What is Camp Dawn?
Camp Dawn is a camping experience for adult survivors of acquired brain injury living in
Southwestern Ontario. The purpose of the camp is to provide survivors with an opportunity to
develop independence and social skills in an outdoor, recreational environment that promotes a
healthy lifestyle. For an individual living with the effects of a brain injury, life can present new
and difficult daily challenges. Such challenges may affect everything from performing simple
daily tasks, to forming and maintaining social relationships, to pursuing recreational
opportunities. While every day may present challenges, Camp Dawn is offered to provide the
opportunity for new adventures and new ways of doing things. It was with this thought that the
slogan “With every dawn a new path is found” was adopted. Visit our website
www.campdawn.ca for more information about the Camp Dawn experience.
When is Camp Dawn?
Camp Dawn will be held at Rainbow Lake, in Waterford, Ontario, southwest of Brantford, from
Thursday, September 17 to Sunday, September 20, 2015. Camp Dawn begins Thursday
afternoon at 1:00 p.m. and concludes at 11:00a.m on Sunday.
Who can come to Camp?
Camp Dawn is open to survivors of acquired brain injury, 18 years and older. Each camper will
be assigned to a cabin and each cabin has a designated leader whose role is to facilitate
participation at camp. The provision of direct care in any way is NOT within the role of the
leader and is not provided by Camp Dawn. Therefore, campers requiring any form of
assistance (i.e. for purposes of self-care, safety, mobility, behavior, etc.) must be
accompanied by their own personal attendant. Partners are permitted only if participating in
the capacity of an attendant. All campers participating without an attendant must be completely
independent in all aspects of their care.
CODE OF CONDUCT
All campers participating in Camp Dawn are expected to behave in a manner that is deemed
appropriate by Camp Dawn. Campers must make their Leader aware of their location at all
times. All Campers must remain on Camp Trillium property for the duration of the camp. Any
individuals, including Campers, who have driven themselves to camp are required to hand in
their vehicle keys upon arrival.
Behaviour which is considered unacceptable may consist of, but is not limited to, any of the
following:
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Inappropriate aggressive communication
Theft
Shoving, hitting, touching, or any other form of unwelcome physical contact
Sexual comments or gestures.
Being under the influence of an illegal substance.
Possession of an illegal substance.
Possession of alcohol.
Possession or use of any weapon (eg. knives)
Forming sexual relationships of any kind
Campers are required to show respect for other campers, leaders and Camp Dawn staff and
volunteers. Campers are also required to respect Camp Dawn property as well as their own
belongings and the belongings of others. Campers shall be held fully responsible for any damage
to any person, including themselves, and/or for any property that results from their behaviour.
Should a camper’s behaviour be deemed inappropriate by Camp Dawn, the camper may, at the
sole discretion of Camp Dawn, be removed from the camp immediately. The camper shall be
responsible for any and all costs associated with their removal from camp and for their return
transportation.
Camp Dawn is not responsible for any stolen, misplaced or damaged items during camp.
By way of signature on the Camp Dawn Application, the Camper agrees to abide by the Camp
Dawn Code of Conduct.
Waiver of Responsibility
In consideration of the fee to attend Camp Dawn and of the other good and valuable
consideration as set out in the Camp Dawn Application, campers agree to release and forever
discharge Camp Dawn Directors, agents, staff and volunteers, including the leaders and
attendants jointly and severally from any and all actions, causes of action, negligence, all liability
and claims of injuries, accidents and death arising out of the campers experience at Camp Dawn
The campers also agree to indemnify and hold harmless Camp Dawn for any action or claim the
camper may make against Camp Dawn relating to their experience at Camp Dawn.
CAMPERS SHOULD BE FULLY AWARE OF THE RISKS OF ATTENDING CAMP DAWN.
INCLUDING INHERENT RISKS WHICH EACH CAMPER IS VOLUNTARILY ASSUMING
IN PARTICIPATING IN CAMP DAWN AND ACKNOWLEDGES BY AGREEING TO THE
TERMS OF THIS WAIVER OF RESPONSIBILITY. THOSE RISKS INCLUDE, BUT ARE
NOT LIMITED TO: WATER HAZARDS, FIRE HAZARDS AND FALL HAZARDS.
Campers shall be fully responsible for their actions and shall accept full responsibility for any
and all risks, including all health care risks and complications that may arise while attending
Camp Dawn (this includes all travel that is provided by Camp Dawn during the Camp
experience.
By way of signature on the Camp Dawn Application the Camper acknowledges having the
opportunity to read and understands and agrees to the terms of the Waiver of Responsibility. It
is the responsibility of the Camper or, where applicable, the Camper’s Attendant or Power of
Attorney, to ensure that the Camper fully understands the terms of the Waiver of Responsibility.
How do you sign up for Camp Dawn?
A limited number of spaces are available. Each individual wishing to attend Camp Dawn must
complete and return an application form with payment of $150 by June 30, 2015. Payment must
be paid by cheque or money order made payable to Camp Dawn. WE DO NOT ACCEPT
CASH, CREDIT CARD OR PAYPAL. Forward the application and payment to:
Camp Dawn
C/O Brain Injury Association of London and Region
560 Wellington St Lower Level
London ON N6A 3R4
Participants will be notified of acceptance by email on August 13, 2015. Your cheque will be
processed at the time you receive your notice of acceptance You will be provided with detailed
information regarding, packing list, medication list, directions to camp, bussing, arrival and
departure times.
Medication Protocol
It is extremely important that each camper brings a complete supply of all medications required
for the full duration of camp. This includes medications that are used regularly and those taken
only when needed. All prescription medication must be clearly identified with the prescription
and marked with the camper’s first and last name. Any non-prescription medication (such as
Tylenol, allergy medication, vitamins, etc.) must be in the original package and clearly marked
with the camper’s first and last name.
All medications will be collected from campers upon arrival at camp and locked in a secure
location which can be accessed as needed. The camper must be able to independently administer
the medication. Camp Dawn is not be responsible for ensuring that the camper has taken the
required medications. Camp Dawn will only ensure that the medication is kept secure and that it
is provided to camper when needed. Should a camper require assistance with the administration
of the medication, this should be clearly identified on the application and the camper will be
required to attend with their own one on one support worker to verify medications are taken as
prescribed.
The original official registration card for use of marijuana for medicinal purposes is the only
acceptable documentation that will permit the use of this substance. A copy of the registration
card must be submitted with the camper application form and the camper must show the original
registration card and the prescription indicating the number of grams per day to the Designated
Medication Board member upon arrival at camp. As with all medications, marijuana will be
locked up.
The camper will be offered a private place away from other campers to administer marijuana.
One camp dawn leader must be present for the entire duration of the administration. Failure to
comply with this Camp Dawn rule will result in the camper being escorted from the camp
immediately.
Agreement to conditions
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Campers requiring any form of assistance (i.e. for purposes of self-care, safety,
mobility, behavior, etc.) must be accompanied by an attendant. All campers
participating without an attendant must be independent in all aspects of their care.
This form must be completed in full
The camp fee must be submitted with this form
Camp fees include transportation, accommodation, meals and snacks, and all activities
while at camp
Group transportation to and from camp will be available from Sarnia, London and
Hamilton.
Campers are responsible for bringing all necessary items required for their stay at camp.
APPLICATION FORM AND AGREEMENT TO CONDITIONS
PLEASE PRINT CLEARLY
Camper Information
Name:________________________________________________________________________
Gender: Male ________
Female________
Address:______________________________________________________________________
City:________________________
Postal Code:_____________________________________
Day Phone:_________________________ Night Phone:_______________________________
Email Address (mandatory):
_____________________________________________________
Date of Birth:____________________
Health Card #:________________________________
Family Doctor’s Name:__________________________________________________________
Family Doctor’s Address:________________________________________________________
Family Doctor’s Phone # include area code:_________________________________________
Will the camper be attending Camp with an attendant? (circle)
YES
NO
***Attendants are required to fill out a leader application
Does the Camper have a legally appointed Power Of Attorney (POA)
for Personal Care? (circle)
YES
NO
If Yes, Name of POA:___________________________________________
Phone # of POA:______________________________________________
Emergency Contact Information
Primary Contact
Name:___________________________ Relationship:__________________________________
Address:______________________________________________________________________
Phone (day-include area code)_____________________________________________________
Phone (night-include area code)____________________________________________________
Alternate Contact
Name:___________________________ Relationship:__________________________________
Address:______________________________________________________________________
Phone (day-include area code)_____________________________________________________
Phone (night-include area code)____________________________________________________
Are you currently receiving rehabilitation supports from a community partner? Please
circle which service you are currently receiving support from
Cornerstone Clubhouse London
London Brain Injury Association
DALE
Brain Injury Services
Hamilton Brain Injury Association
HILL
Hamilton Health Sciences
Windsor Brain Injury Association
CHIRS
Anagram
Sarnia
BICRI
Chrysalis Club
Other:__________________________________________
Medical Information
Do you wear a medical alert bracelet?(circle)
Y
N
If Yes list reason for medic alert:_______________________________________________
Date of last Tetanus Shot (Must be within last 10 years)________________________________
Please tell us if you have any allergies or dietary requirements:
______________________________________________________________________________
______________________________________________________________________________
Please note**NO outside food is permitted on the campgrounds. Camp Trillium is a peanut-free,
nut-free facility and does not allow ANY food to be brought into the site.
Do you have an epipen that you carry for your allergies? (circle)
YES
NO
Do you have difficulty with chewing and swallowing food or drinks? Do you often cough and or
choke when you eat? Please explain:
______________________________________________________________________________
______________________________________________________________________________
Have ever experienced a seizure? (circle)
YES
What is the average frequency and duration of your seizure activity?
NO
 Once a week
 Once a month
 Once every 6 months
 Once a year
 It has been over a year. Last known seizure _____________________
Average duration of a seizure ______________________
Do you have difficulties with either of the following, please provide an explanation so we can
accommodate as needed:
Vision:________________________________________________________________________
______________________________________________________________________________
Mobility: If you have problems with mobility and are not in a wheelchair please provide us with
an idea of maximum distance you can walk:
______________________________________________________________________
______________________________________________________________________________
Communication:________________________________________________________________
_____________________________________________________________________________
Will you be bringing a CPAP machine to Camp Dawn? (circle)
YES
NO
Please check the following devices you will be bringing to camp with you to assist with your
mobility:
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

Electric Wheelchair
Manual Wheelchair
Walker
Cane
Please list any other assistive devices you will be bringing to camp:
______________________________________________________________________________
Have you fallen recently? Please explain:
______________________________________________________________________________
______________________________________________________________________________
Will you require the use of a commode chair? (circle)
Will you require the use of a bath bench? (circle)
YES
YES
NO
NO
(Camp Dawn will provide the use of a commode chair or bath bench)
If assistance is required with any of the following please check and explain:
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Taking medications
Toileting
Bathing
Feeding
Transfers
Other
______________________________________________________________________________
Do you exhibit behaviours that we should be aware of? If so please explain what situations may
cause a behavior and include the strategies that work best for you when dealing with these
difficult situations. Please understand that disclosure of behaviour does not exclude you from
attending camp but rather gives the leaders a better idea on how we can support you!
______________________________________________________________________________
______________________________________________________________________________
Is there any other information that you would like to share with Camp Dawn that will help
ensure your safety and well-being while at Camp Dawn?
______________________________________________________________________________
______________________________________________________________________________
ALL CAMPERS are required to complete the Medication Information Sheet with their
application. Should you have changes to your medications prior to camp you are required to
bring an updated Medication Information Sheet with you to camp. In the event of an emergency
this is the information that will be provided to Emergency Medical Services. Campers are
required to hand in all medications including over the counter medications upon check in at
Camp.
Camp Dawn Medication Information Sheet
Name:________________________________________________________________
Health Card Number:____________________________________________________
Allergies:______________________________________________________________
Special Notes:__________________________________________________________
Name of Medication Dose Frequency Breakfast Lunch Dinner Bed AS NEEDED (PRN) ALL MEDICTATIONS YOU ARE BRINGING TO CAMP WITH YOU MUST BE DETAILED ON THIS SHEET. BOTH PRESCRIBED AND OVER THE COUNTER MEDICATIONS. Please Circle which is your preferred pick up/drop off site:
London
Sarnia
Hamilton
Consent Forms Photographs and/or videotapes may be taken at camp and used for Camp Dawn promotional
purposes.
Please check here if you DO NOT wish to be photographed or videotaped
 NO, I do not wish to be photographed or videotaped.
Please note-if you check the above box, you will NOT be allowed to participate in the group
picture
Camp Dawn cannot be responsible for pictures or video taken by campers for personal use.
Adventureworks!
If you are interested in participating in a high/low ropes course, please complete the
Adventureworks! Forms (attached) and send with this application.
Acknowledgement
I have reviewed the Camp Dawn camper information/application package. I understand and
agree to abide by the Code of Conduct, Waiver of Responsibility and Agreement to Conditions.
By signing this document I understand the risks associated with attending Camp Dawn. Risks
include but not limited to: Camp fire hazards, water hazards (i.e. canoeing and boating on the
lake) and fall hazards (i.e walking on uneven surfaces).
Signature of Camper:_____________________________________
Signature of Power of Attorney for Personal Care (if applicable):_________________________
Please print name of person signing:________________________________________________
Date:_________________________________________________________________________
For More Information Contact:
Camp Dawn C/O Brain Injury Association of London
560 Wellington St, Lower Level
London, ON N6A 3R4
Phone : 519.642.4539
Fax : 519.642.4124
campdawninfo@gmail.com
102 Plaza Drive
Dundas, Ontario, L9H 4H0
Phone: (905) 304-5683
Fax: (905) 304-0386
Email: info@adventureworks.org
Website: www.adventureworks.org
Health and Safety Form
Adventureworks! is committed to delivering unique and exciting learning experiences that lead to positive growth and
development in all individuals, groups, organizations and communities. Because of the physical nature of our programs, and
because most programs take place in the outdoors, all participants are required to provide accurate health and medical
information. In cases where there is some concern about one’s ability to participate for health reasons, a medical examination
by a physician may be advisable. Please note that Adventureworks! is not liable for any costs incurred during such an
examination. All health information will be held in the strictest confidence and not given to a third party.
Please complete all sections:
Name of Group_________________________________________ Dates of Program_____________________
Name of Participant_____________________________________ Date of Birth ________________________
Home Address _____________________________ City _____________________ Postal Code ___________
Phone # (home) ________________ Email address ___________________ OHIP # _____________________
Emergency Contact Name: _____________________________________ Relationship ___________________
Home Address: ____________________________ City: _____________________ Postal Code ___________
Phone # (daytime) ______________________ (evening) ______________________
Please list any disabilities, special needs, recent injuries, illnesses or operations and any subsequent limitations
Please list any medications, prescribed or otherwise, currently being taken (Please bring Epipen(s) if required)
Please list any allergic reactions to medications, food or environmental factors:
Allergy
Reaction
Treatment
No
____________________
_________________________
_______________________
____________________
_________________________
_______________________
Epi Pen Required?
Yes
!
!
!
!
!
!
____________________
_________________________ _______________________
Please describe any previous emergency treatment (injection, doctor, emergency room, hospital) in detail:
__________________________________________________________________________________________
Authorization For Seeking Treatment of Minors
In the event of accident or apparent illness, I irrevocably authorize Adventureworks staff to secure emergency
medical services and treatment for this participant if, in their judgment, such services or treatment are necessary. I
understand that in the event of a medical emergency every effort will be made to contact parents or guardians.
Parent/Guardian ________________________ Signature ______________________ Date _________________
Participant Parent/Guardian
Initials
Initials
____
____
Photo Release
I give permission for photographs or videotapes of me (or my child) to be used by
Adventureworks! for promotional purposes.
102 Plaza Drive, Box 63012
Dundas, Ontario, L9H 4H0
Phone: (905) 304-5683
Fax: (905) 304-0386
Email: info@adventureworks.org
Website: www.adventureworks.org
Assumption of Risk and Responsibility Form
Adventureworks! programs can utilize activities which require a high level of physical activity. As a participant, you may
be involved in activities such as: cooperative games, trust exercises, group initiative tasks, low and high ropes course, and
rock climbing. Adventureworks! utilizes an “I-OPt” design philosophy in all of its programs. This means that
Adventureworks! staff will provide a variety of mentally and physically challenging activities and that you will be
empowered to make choices about your own level of involvement. Adventureworks is committed to ensuring your safety at
all times. Our staff will provide you with safe instruction, high quality equipment, and appropriate supervision for all
activities. You must do your part by following all safety policies and procedures that are outlined during the course of the
program. In order to protect you from harm you will be spotted in all “low ropes” activities, and protected by a “belay”
system while involved in all high ropes and rock climbing activities.
Participant Name: ____________________________
Group Name: ______________________________
Participants (and parent/guardian if under 18) must read and initial all of the following statements:
Participant Parent/Guardian
Initials
Initials
eg. AW
_RW
____
____
I agree NOT to use illegal drugs or alcohol at any time during an Adventureworks! program.
____
____
I accept the fact that neither Adventureworks! nor its staff can guarantee my total safety
because some risks are beyond their control.
____
____
I agree to follow all instructions given by the staff and to act safely and responsibly at all
times.
____
____
I am sufficiently fit (socially, mentally, physically) to participate in this program.
____
____
I have completed the Health & Safety Form with information that is accurate, complete
and true to the best of my knowledge.
____
____
I agree to notify Adventureworks! of changes to my health and fitness that occur during the
program.
____
____
I fully comprehend and willingly assume the risks and responsibilities of participation in this
program.
I/we have read the above information, and agree to the terms of the Assumption of Risk and Responsibility.
PARTICIPANT Signature: _______________________________________
DATE: ___________________
PARENT/GUARDIAN Signature (if under 18): _________________________ DATE: ___________________
Photo Release: Occasionally Adventureworks! will take photos for use in promotional materials.
Participant Parent/Guardian
Initials
Initials
eg. AW
_RW
____
____
I give permission for photographs or videotapes of me (or my child) to be used by
Adventureworks! for promotional purposes.