***KEEP THIS PAGE FOR YOUR RECORDS***

HELP Foundation, Inc.

Summer Program 2018
Application for Enrollment
HELP Foundation, Inc. with the support of the Cuyahoga County Board of Developmental
Disabilities is again offering a summer program for children with developmental disabilities.
HELP will also provide Extended School Year services for all qualifying students. This service
will provide eligible applicants with essential continuity in five areas of development: 1)
cognition, 2) gross and fine motor skills, 3) receptive and expressive language acquisition, 4) self
help training, and 5) socialization. The Summer Program will also include two nutritious meals,
and outdoor recreational activities. There will be two locations, Parma and Euclid. The HELP
Program will operate Tuesday through Friday this year. The actual dates of the Program are
June 12th through July 20th.

The deadline for completed application submission is Wednesday, May 23rd, 2018. Only
those applications displaying the Year 2018 will be processed.

*NOTE*: HELP FOUNDATION AND THE CUYAHOGA COUNTY BOARD of DD

WILL NOT BE TRANSPORTING ANY STUDENTS THIS SUMMER. Please contact
your school district if you are unable to provide transportation, and inquire if they are able
to assist you with transportation. Transportation for students will be the responsibility of
the parents/guardians, or the local school district if the student is determined eligible for
Extended School Year Services.

*Participation in previous HELP Foundation Summer Programs does not guarantee

acceptance for the 2018 season.

The following criteria will be considered when selecting applicants for the HELP Summer
Program.
1. Applicants should be between three and twenty-one years of age.

2. All children who are eligible for services from the Cuyahoga County Board of Developmental
Disabilities will be considered for enrollment. However, individual decisions will be made to
determine the appropriateness of any applicant whose particular disability, medical status and/or
behavior may require a fundamentally different environment or a specific approach that cannot
be accommodated within our present program structure.

3. Since enrollment is limited, it is ESSENTIAL to complete the packet correctly and

COMPLETELY. THOSE APPLICANTS WHO DO NOT MEET THE DEADLINE OR WHO
SUBMIT THEIR APPLICATION AFTER THE PROGRAM HAS BEEN FILLED, WILL BE
PLACED ON A WAITING LIST.
THOSE SUBMITTING INCOMPLETE FORMS WILL NOT BE CONSIDERED FOR
PROGRAMMING UNTIL ALL PAPERWORK IS COMPLETE AND RETURNED. No
child will be accepted into the HELP Foundation’s Summer Program if any of the
necessary information is omitted.
4. The Medical Examination (C) is a requirement for ALL applicants is NOT due until
Wednesday, May 23rd, 2018.

5. Camp is available for those not receiving ESY (Extended School Year) services.
The Cuyahoga County Board will cover the camp cost IF the individual is county board eligible
prior to the start of camp on June 12th. If they are not eligible at that time, the camp cost is $840
for the entire camp. ESY is covered by school districts at the cost of $2100 for the entire
session. Check with your district if ESY is approved in your child’s IEP

6. The Teacher Assessment Packet (B) must be completed by the child’s classroom teacher and
returned with the rest of the Summer Program application or mailed in by the teacher or emailed
to us by May 23rd. It is the responsibility of the parent/guardian to forward this packet to the
teacher and to encourage them to send it in by the due date.

7. The parent or authorized guardian must sign all permission forms, including the Emergency
Medical Authorization Form.

8. The Application Checklist (page 2) must be completed and returned with your packet.

9. Please note that the HELP Foundation reserves the right to change the site placement based on
operational needs.
 A

HELP Summer Program 2018

Checklist
The following checklist will assist you in the completion of the enrollment/application packet. This checklist
must be completed and returned with your Application Forms and mailed or delivered to:
HELP Foundation, Inc.
26900 Euclid Ave.
Euclid, Ohio 44132

Child’s Name_____________________________________________________________
_____ The Application pages 2-6 (A)**Due date May 23rd, 2018
**Keep the coversheet for your records.
_____ Teacher Assessment Packet (B) ** Due date May 23rd, 2018
_____ Physical (C) completed and signed by a licensed physician
_____ a) Physical Exam (pages 1-3) completed and signed by the child’s doctor.
**Due date May 23rd 2018
_____ b) Request to Administer Medication (page 4) completed and signed by child’s
doctor, if applicable.
**Due date May 23rd 2018
_____ c) Special Diet (page 5) must be completed and signed by child’s doctor.
**Due date May 23rd 2018
_____ d) Tube Feeding Permission (page 6) must be completed and signed by child’s
doctor, if applicable.
**Due date May 23rd 2018
_____ Copy of most recent IFSP or IEP (Must be sent with this packet) ** Due date May 23rd,
2018
*NOTE – NO TRANSPORTATION WILL BE PROVIDED for those NOT receiving ESY.
_____ I have enclosed all of the above information.
_____ I have not enclosed the following item(s) ______________________________________
Explanation: __________________________________________________________________
Signature:______________________________________________Date: __________________
Should you have any questions or need assistance please contact Greg Seigler, Summer Program
Director, at (216) 432-4810 Ext. 321.
 A

HELP Summer Program 2018

Enrollment Application

Name of Child: ____________________________________ Date of Birth: ____________________________

Parents’/Legal Guardians’ Names________________________ Email_________________________________

Address: _______________________________________________ Telephone: (____)___________________

__________________________________________________________________________________________
City State County Zip

Height: ________ Weight: _______ Sex: _______

Is your child able to walk independently? Yes _______ No _______

Child’s Ethnic Background (check one): Asian: ________ White: ________ African-American: ________
American Indian: ________ Hispanic: ________ Other: ________

What school is your child attending at present? ______________________________________________

Name of Child’s Classroom Teacher: ________________________ Phone Number: _______________________

If the student becomes ill at school and needs to go home and the parents/guardians cannot be contacted, please
contact the following alternate person/persons. They must be able to transport the child home:

Person Relationship Phone Number

__________________________ _________________________________ _____________________
__________________________ _________________________________ _____________________
_________________________ _________________________________ _____________________

*Does your child have a private nurse? Yes _____ No _____

If yes, the nurse must be provided by the parent/school in order for your child to be eligible for the program.
NOTE: said nurse will need to be fingerprinted and drug tested.

Is your child currently eligible for Extended School Year (ESY) services for summer of 2018? Yes ___ No ___
If no, please go to next page. (Page 4)
If yes, official documentation of eligibility MUST be provided by the school district. This should be sent to the
HELP Office on school district letterhead and be signed by a school district representative.

Name of school district: ______________________________________________________________________

Special Education Coordinator: ___________________________________ Phone Number: ________________

 A

HELP Summer Program 2018

Permission Forms

***Note: Your signature is required on lines A and B, Line C is optional.

Information
I give my permission for the release to HELP Foundation, Inc., of information from our records, which will

be helpful in understanding: __________________________________________ _____________________

Child’s Name Date of Birth

Information requested from: A. ________________________________________ ____________________

Legal Guardian Signature (Required) Date

I give my permission to HELP Foundation, Inc. for the release of all information pertinent to

___________________ performance in the HELP Summer Program. HELP Foundation, Inc. anticipates sending
(Child’s Name)
final report information to the Cuyahoga County Board of DD/school, referral source and physician.

B. ___________________________________________________ _____________________________
Legal Guardian Signature (Required) Date

Photographs

The undersigned hereby gives permission to the HELP Foundation, Inc. and its assigns (designated staff and

volunteers) to utilize in part, or in whole, for instructional or promotional purposes, photographs/videotapes, in

both print and non-print materials. This may include but not be limited to brochures, newsletters, and websites

and agency social media sites.

C. ___________________________________________________ _____________________________
Signature (Optional) Date
**NOTE: All client information remains confidential. Parents and/or legal guardians can obtain a copy of any and all of the HELP
Foundation Policies and Procedures specific to the Summer Program upon request to the attention of the Summer Program Director.
Information regarding the Agency’s Due Process Procedures can be acquired in the same manner.
 A

HELP Summer Program 2018

Emergency Medical Authorization

Child’s Name: _________________________________________ Birth Date: __________________________

Parent Name:__________________________________________ Phone: (_____)_______________________
Address:____________________________________________________________________________________
City:____________________________________________ Zip Code: _________________________________
EMAIL ADDRESS:__________________________________________________________________________
Diagnosis/Disability: ___________________________________________________________________________
Medicaid Number or Hospitalization Insurance:_______________________________________________________
Language Spoken at Home:____________________________________________________________________

Purpose - To enable parents to authorize emergency treatment for child/adolescent who become ill or injured while
at the summer program, when parents cannot be reached.
TO GRANT REQUEST
In the event reasonable attempts to contact me, _______________, at _______________ or _______________
(Parent/Guardian’s Name) (Phone Number) (Other Parent or Relative)

at______________ have been unsuccessful, I hereby give my consent for (1) the administration of any treatment
(Phone number)

deemed necessary by Dr. ________________, at ______________ or Dr. _____________, at ______________

(Preferred Physician) (Phone Number) (Preferred Dentist) (Phone Number)

or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist;

and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover any major surgery unless the medical opinions of two other licensed physicians or
dentists, concurring in the necessity of such surgery, are obtained before surgery is performed.

Allergies and/or physical conditions to which physician should be alerted:

ALLERGIC SUBSTANCE REACTION/SYMPTOMS
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Medication Currently Taken, Dosage and Time Given:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

_____________________ __________________________________________________________________
Date Signature of Parent/Guardian
 A

HELP Summer Program 2018

Authorization to Release Child
To Person Other Than Parent or Guardian

In order to assure the safety of children in the HELP Summer Program and to meet the needs of the children’s
parents/guardians regarding authorization to release their child from the HELP Summer Program, the following
procedure will be followed:
• Children will be released only to their parents or guardians unless prior permission is obtained from the
parents or guardians.
• Each child will have an Authorization to Release Child form completed by the parent/guardian prior to
the initiation of the program. This form will specify the names of the individual(s) the HELP Summer
Program is authorized to release the child to and must be signed by the parent/guardian.
• On an emergency basis the parent/guardian may call the HELP Summer Program and authorize an
individual not mentioned on the Authorization to Release Child form to pick up his/her child.
• Proper identification will be required of all individuals, other than the parent/guardian prior to picking
up a child from the HELP Summer Program.
• A sign-out log will be maintained at the front desk. When a parent/guardian or other authorized
individual picks up a child from the Program that individual will fill out and sign the log, provide proper
identification (picture identification) at which time the child will then be released.
• The parent/guardian may at any time change the terms of the Authorization to Release Child form by
adding or deleting an authorized individual.
Authorization to Release Child

Child’s Name: _____________________________________________

Name of Individual(s) Granted Authorization Relationship to Child
______________________________________________ _____________________________

______________________________________________ _____________________________

______________________________________________ _____________________________

I grant the HELP Summer Program permission to release my child to the above named individual(s) with proper
identification. I realize that I may change the terms of this authorization at any time by notifying the Program
Site Director and adding an authorized individual.

Name (Please print): ________________________________________________________________________

Signature: ________________________________________________________________________________

Relationship to Child: _________________________________________________Date__________________

 TEACHER ASSESSMENT B

Teacher Name___________________________________Phone____________________(School or Home)

email _________________________________________ School Attending ________________________

Student Name__________________________________
Does this student have Extended School Year services? Yes No To be Determined

TOILETING NEEDS: PLEASE CHECK APPROPRIATE BOX

YES NO COMMENTS
Diapers
Communicates need to be changed how?
Toilet Conditioned
Toilet Trained
Communicates need to use toilet how?
Accidents

DRESSING SKILLS: PLEASE CHECK APPROPRIATE BOX

UNDRESSING: DRESSING:
SELF PROMPTS COMMENTS SELF PROMPTS COMMENTS
NEEDED NEEDED
SHIRT SHIRT
PANTS PANTS
SOCKS SOCKS
UNDERWEAR UNDERWEAR
COAT COAT
SHOES SHOES

EATING SKILLS: PLEASE CHECK APPROPRIATE BOX

SELF ATTEMPTS W/HELP UNABLE COMMENTS
sucks from straw
drinks from cup
finger feed
uses spoon
uses fork
helps clean up

YES NO COMMENTS
throws food
grabs food
has trouble sitting near
other students

Predominant hand used for eating: Right Left Both

PAGE TWO
GROSS MOTOR SKILLS: PLEASE CHECK APPROPRIATE BOX B
IS CHILD AMBULATORY OR NON-AMBULATORY? _____________________
EQUIPMENT USED CIRCLE ALL THAT APPLY: WHEELCHAIR GAIT TRAINER WALKER

NON-AMBULATORY ONLY:
SELF ATTEMPTS W/HELP UNABLE COMMENTS
rolls on floor
crawls/scoots
sits
stands/wt. bears
manipulates wheelchair
transfers/bears weight

AMBULATORY ONLY:
SELF ATTEMPTS W/HELP UNABLE COMMENTS
gait steady on different terrains
walks up/down stairs
alternates feet on stairs
runs

FINE MOTOR SKILLS:

SELF ATTEMPTS W/HELP UNABLE COMMENTS
able to grasp objects
holds objects in hands
makes purposeful marks/paper
colors in lines
holds scissors correctly
cuts

ACADEMIC:

recognizes name in print unable able

consistently uses unable right left both
counts unable up to 5 1 to 10 higher
recognizes and names numerals unable 1 to 5 1 to 10 higher
identifies shapes unable which ones? _____________________________________________________
identifies colors unable which ones? _____________________________________________________

PAGE THREE
COMMUNICATION SKILLS/LANGUAGE: B
Verbal____________ Nonverbal___________

Prompts needed by the student to communicate (check all that apply)

________Verbal Prompts list common prompts ___________________________________
________ Modeling
________ Physical Prompts (touch machine, picture cards, etc.) types of prompts ___________________
________ Gestures types of gestures used _____________________________________

Hearing (circle one) hearing aids deaf no problems

Vision (circle one) glasses blind no problems

Receptive Language
Follows verbal directions (circle one) one step two step three step
Additional cues needed to follow verbal directions
________ Sign Language (list signs needed) ____________________________________
________ Actual photographs used (list) ________________________________________
________ Symbols or Picture icons used (list) ____________________________________
________ Physical Prompt (how e.g. touch chair, touch shoulder)
(list) _______________________________
________ Gestures (list e.g. points, takes adult hand, etc.) (list) _______________________________

________ Eye Gaze

Expressive Language
Verbal-speaks clearly Yes No
Check all appropriate areas (common words or phrases that the students uses) ___________________________
________ Echolalic

________ Delayed response how long?______________________

________ Meaningful non standard word (list e.g. "boo" = no or "tinkle" = bathroom)
_____________________________________________

COMMUNICATION SKILLS/LANGUAGE CONTINUED:

Non verbal
Check all appropriate areas the student uses to communicate:
________ Photos (list) ____________________________________________
________ Symbols or picture icons used (list) __________________________
________ Gestures (give e.g.) _____________________________________
________ Eye Gaze

Is a communication device used at school? YES NO What type?____________________________

Is the device available to use in the summer? _________________________

PLEASE CHECK APPROPRIATE BOX TO DESCRIBE METHOD:

physical with with with
unassist prompts pictures cues signs
follows classroom rules/schedule
makes transitions

If the student uses sign language list signs:

PAGE FOUR
BEHAVIORAL NEEDS: B
Is the student on a Behavioral Plan? Yes No

IF YES, PLEASE SUPPLY US WITH A COPY.

Is the student on a Sensory Diet or Sensory Plan? Yes No

IF YES, PLEASE SUPPLY US WITH A COPY.

DOES THE STUDENT HAVE A ONE-ON-ONE AIDE? Yes No

Please explain: (Parent supplied, district paid, allocated through IEP process or extra staff assigned to student exclusively)
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Aggressive Behaviors Describe______________________________________________

yes no ____________________________________________________
When does it happen?_____________________________________

What is your response?____________________________________

Interventions used that work with the student: _________________

____________________________________________________

Self Abusive Behaviors

yes no Describe______________________________________________

When does it happen?_____________________________________

What is your response?____________________________________

Acting Out Tantrums Describe______________________________________________

yes no When does it happen?_____________________________________

What is your response?____________________________________

Time Outs Used Describe the way time out is implemented: __________________
yes no ___________________________________________________

Does it work? yes no

Duration of time in time out__________________________________

Running/Wandering from Group When does it happen?____________________________________

yes no
Response________________________________________________

PAGE FIVE
 B

Health Concerns:
Seizures:

Medications:

Special Diet:

Allergy:

Other:

Has there been a significant health change this school year (ex: hospitalization, diseases,
injuries?)

How has this affected programming or student's needs?

Other concerns you wish to mention at this time?____________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

PAGE SIX
 HELP Summer Program 2018
B
Application for Enrollment

TEACHER ASSESSMENT
Parents: Please read carefully and send to your child's classroom teacher!!

Please fill in the necessary information and sign your name to the release form below before
sending it to your child's classroom teacher.

I,______________________________, am the ________________ of

(Parent/Guardian) (Relationship) (Child's Name)

I give my permission to
(Teacher's Name)
to release information concerning my child's abilities and educational performance to the HELP Foundation.

Signature ___________________________________________________________

DEAR TEACHER:

_____________________________ is applying for admission into the HELP Foundation's

(Child's Name)
Continuing Education Summer Program. In order to address the child's needs and to

obtain a clear understanding of his/her ability, we are asking you to complete the attached

assessment. Most of the information requires a simple check mark, and we anticipate that

the entire assessment should not take longer than 15 minutes to complete. Once you have

finished it, kindly send it home ASAP with the child or mail it to us in the self-addressed envelope by May 23rd, 2018

or fax it to us at (216) 415-6222. For your convenience, a signed release form has been included at the top of this page.

Thank you for your cooperation and timely response in attending to this matter.

If you have any questions, please contact me:

Sincerely,

Greg Seigler
Summer Program Director
216-432-4810 x321
Fax (216) 415-6222
 C

HELP Summer Program 2018

Medical Report Examination of Program Applicant

MUST BE COMPLETED BY A LICENSED PHYSICIAN AND RETURNED TO HELP OFFICE BY

MAY 23RD 2018

Child’s Name__________________________________________________ Sex ___________

Address _________________________________________________________________________
Date of Birth ________________________ Phone Number (_____)___________________

PART ONE: Examination Date of Exam: _____________________

**MUST be after July 21st, 2017**
DIAGNOSIS: _____________________________________________________________________

ALLERGIES: _____________________________________________________________________
Height_______________ Current Weight________________ Weight last yr.________
Eyes___________ Vision: Right __________ Left_____________ Skin_____________
Nose __________ Mouth/Throat_________ Teeth (condition)_____________________
Head and Neck ___________________ Ears: Right_____________ Left____________
Speech______________________________ Hearing defects ____________________
Chest ______________________________ Lungs _____________________________
Cardiovascular_______________________ Blood Pressure _________ Pulse _______
Breasts _________ Abdomen ________________ Hernia ______________________
General Physical Description _______________________________________________
Any History of Infection ___________________________________________________
Any History of Incontinence ________________________________________________
Genitourinary _______________ Anorectal Exam___________ Gyne______________
Spine __________________________ Extremities ______________________________
Neurological Findings _____________________________________________________
Seizures __________ Type _____________________ Frequency ________________
Limitations of Motion _____________________________________________________
Congenital Abnormalities __________________________________________________
Degenerative Disease ______________________________________________________

1
 C
PART TWO:
IMMUNIZATION PROOF
D.P.T.
D.T.
POLIO
HIB
HEPATITIS B
VARICELLA
MMR
TB TEST

Does the child have a history of any of the following conditions? If so, please check.

( ) Arthritis ( ) Cystic Fibrosis ( ) Hypothyroidism

( ) Asthma ( ) Diabetes ( ) Leukemia
( ) Autism/Asperger’s ( ) Eczema ( ) Meningitis
( ) Behavior Concerns ( ) Epilepsy ( ) Osteogenesis Imperfecta
( ) Cancer ( ) Gastric/Duodenal Ulcer ( ) Sickle Cell Anemia
( ) Cerebral Palsy ( ) Hearing Impaired ( ) Spina Bifida
( ) Chronic Kidney Disease ( ) Heart Disease ( ) Tachycardia
( ) Circulatory Disorder ( ) Hydrocephalus ( ) TB
( ) Congenital Heart Disease ( ) Hypertension ( ) Visually Impaired

( ) Psychiatric Diagnosis- please specify: ______________________________________________

Other: __________________________________________________________________________

Past Surgical Operations:

_________________________________________________________________________________________
_________________________________________________________________________________________
Past Injuries:
_________________________________________________________________________________________
_________________________________________________________________________________________

Recurring Medical Problems:

________________________________________________________________________________________

2
 C
PART THREE:
CURRENT MEDICATIONS:
ANY MEDICATION THAT NEEDS TO BE GIVEN BETWEEN 8:00 A.M. AND 4 P.M. WILL NEED AN
ORDER- SEE PAGE 4. (ONE ORDER PER PAGE)

NAME DOSAGE FREQUENCY COMMENTS PRESCRIBING

DOCTOR

*DO YOU BELIEVE IT TO BE DETRIMENTAL TO THIS CHILD’S HEALTH TO GO OUTSIDE ON

VERY HOT AND HUMID DAYS? IF YES, PLEASE EXPLAIN.
YES ( ) NO ( )
Explain YES: _____________________________________________________________________________

I CERTIFY THAT NO COMMUNICABLE DISEASE IS EVIDENT AT THE TIME OF THIS

EXAMINATION:

YES ( ) NO ( )

___________________________________________ _________________________________________
Signature of Physician Date Printed Name of Physician

___________________________________________ _________________________________________
DATE OF EXAM (Must be after July 21st, 2017) Address

___________________________________________ _________________________________________
Phone Number Fax Number

ORIGINAL FORM MUST BE SENT TO: HELP FOUNDATION, INC.

26900 Euclid Avenue
Euclid, OHIO 44132
Or faxed to: (216) 415-6222

3
 C

HELP Summer Program 2018

Medical Report Examination of Program Applicant

MUST BE COMPLETED AND SIGNED BY A PHYSICIAN

PHYSICIAN’S REQUEST FOR CHILD TO BE PROVIDED THE FOLLOWING

MEDICATION/TREATMENT BY PROGRAM NURSE

**ONE ORDER PER PAGE**

Is this medication/treatment necessary for the health and well-being of the child during program hours?

Yes ( ) No ( )

Child’s Name ____________________________________________________ Date _____________________

Address __________________________________________________________________________________

Medical Reason for Medication/Treatment ______________________________________________________

Description of Medication/Treatment __________________________________________________________

Dose and Time of Medication/Treatment _______________________________________________________

Possible Side Effects of same ________________________________________________________________

Special Storage Conditions of same ___________________________________________________________

Authorization must be renewed annually or whenever there is a change in dosage, etc.

Physician’s Signature Phone Number Fax Number

Parent/Guardian/Care Giver’s Signature

4
 C

HELP Summer Program 2018

Medical Report Examination of Program Applicant

MEDICAL STATEMENT OF CHILD’S DIETARY NEEDS

**MUST BE COMPLETED BY A PHYSICIAN**

Child’s Name: ______________________________________________ Age: _________________________

Diagnosis: ________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Describe the medical or other special dietary needs that restrict the child’s diet: _________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

List food(s) to be omitted from diet and foods(s) that may be substituted (Diet Plan): _____________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Special Dietary Equipment: __________________________________________________________________

_________________________________________________________________________________________

_________________________________ _______________________________________________
Date Signature of Medical Authority

5
 HELP FOUNDATION SUMMER PROGRAM
Treatment/Nursing Task Permission for Gastrostomy/Jejunostomy Tube Feeding

Return On/Before May 23rd 2018

Name of Individual_______________________________________________________________

Address________________________________________________________________________

Type of Tube Jejunostomy Gastrostomy

May individual have oral feeds? Yes No

If “yes” provide type of food/liquids and when: ______________________________________________

____________________________________________________________________________________

Feeding/Formula_____________________________________________________________________

Delivery: Bolus Gravity Drip Pump

Amount________cc Time to be performed____________________Rate _________________

Check residual Yes No

If “yes” provide instructions: _____________________________________________________________

Flush: Before Feed Amount of Water:_______cc After Feed Amount of Water_____cc

May a licensed trained nurse attempt to reinsert this tube? Yes No

Time frame in which tube must be reinserted:__________________________________

Recommendations if tube becomes dislodged:__________________________________________

Positioning of individual during feeding:_________________________________________________

List possible adverse reactions to be observed during the performance of this treatment/task:_________

_____________________________________________________________________________________

The tube is stable, feed may be performed by a trained, unlicensed personnel: Yes No

Date of order_________________________

Authorization must be renewed annually or whenever there is a change in the treatment order

_________________________________ _______________________________________

Prescriber’s Signature Date Prescriber’s Name (Print) Phone #

I give permission for this tube feeding to be performed during HELP’s Summer Program by a licensed nurse or personnel as delegated by licensed
register nurse. I agree to notify HELP personnel of changes in prescriber’s instructions or if tube feeding is discontinued. In the event of an adverse
reaction involving tube feeding, the HELP nurse will be notified and/or prescriber at the number listed.

___________________________________ ____________________________________

Parent/Guardian Signature Telephone number