ALL KIDS HAVE FUN!

Parent/Guardian Information *

First Name

Last Name

Phone

(###)

###

####

Camper Information

First Name

Last Name

Summer Camp Weeks *

Please select the weeks you require support for your child. When a space becomes available, you will be contacted directly by our Inclusion Director.

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

I am flexible for any days available

Does your child wear diapers and require diaper changes? *

Yes

No

Does your child wander or run away from adults? *

Yes

No

Does your child have difficulty walking independently? *

Yes

No

Does your child have difficulty running independently? *

Yes

No

Does your child have difficulty climbing independently? *

Yes

No

Does your child have difficulty sitting independently on the ground? *

Yes

No

Does your child require support to stand independently? *

Yes

No

Does your child use a wheelchair or stroller for transportation? *

Yes

No

Does your child require assistance with feeding themselves? *

Yes

No

Is your child tube fed? *

Yes

No

Does your child require a special diet? *

EX. pureed, minced, thickened

Yes

No

Does your child engage in self-harm or harm to others? *

Yes

No

Does your child have hearing impairment or are they deaf? *

Yes

No

Does your child communicated with ASL? *

Yes

No

Has your child required 1:1 support at a day camp before? *

Yes

No

Does your child have any fears or phobias? *

Yes

No

Does your child seek or avoid certain sensory experience? *

Loud noises, bright lights, textures, people's touch, etc.

Yes

No

Does your child require any equipment or assistive deveices?

Yes

No