EmailMe Form - Jammin Jubilee Registration Form

Camper's Name

First Last

Camper resides with:

Name1

First Last

Relationship to camper

Address1

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

County

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Work Phone

### - ### - ####

Email

Occupation

Company

Name2

First Last

Relationship to camper

Address2

Same as above

Different Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

County

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Work Phone

### - ### - ####

Email

Occupation

Company

Who else is authorized to pick up your child from camp?

Name

Phone

### - ### - ####

Relationship to camper

Name

Phone

### - ### - ####

Relationship to camper

How did you hear about the camp?

Camper Information

Please tell us about your camper

Name

First Last

Height

Weight

Gender

Date of Birth

MM / DD / YYYY

Chronological Age

Developmental Age

Does your camper attend school?

Where?

Where does your camper fall in the autism spectrum?

What special equipment does your camper use?

include hearing aids, glasses, wheelchair, etc.

Medical Information

Please check any that apply and provide any other neccesary information.

Please provide further details if necessary

Please list any known allergies to medication, environmental, animal, food, etc

Pleae give detailed information on any other conditions and special needs your camper has

If your camper needs constant adult supervision due to aggressive tendencies, pease explain what his/her adult buddy should know

Does your camper's aggressive tendencies require him/her to be separated from younger or weaker children for safety reasons?

Please explain

MEDICAL AND INSURANCE CONTACTS

In case of an emergency, the following information is helpful.

Camper's Primary Physician

First Last

Phone

### - ### - ####

Do you have a medical plan of care for emergency procedures?

If yes, please send us a copy. The same plan that you have for school or a daycare provider would be great.

Insurance Provider

Policy Number

Will medication be needed during camp?

If yes, please explain

Can a volunteer buddy be trained to administer?

Please explain any other special care instructions required for you camper during the camp

MOTOR SKILLS

Camper's fine motor skill disability level (ie handling small items)

Camper's gross motor skill disability level (ie larger movements)

COMMUNICATION SKILLS

What are the primary ways that your child communicates with others?

Check all that apply

Speaks clearly

Requires prompts/cues to initiate

Vocalizations not always understood

Requires prompts/cues to interact

Follows spoken requests

Responds to signed or gestural requests of instructions

Can express basic needs and wants by using:

Eye gaze/contact

Gestures, give example:

Signs, give example:

Assistive technology (picture boards, books, talkers), please describe:

How does your camper indicate "yes" or "no" when asked if he/she wants something, wants to go somewhere, or wants a person?

Will your camper us other behavior(s) to communicate a want/need (cry, hit, run away)?

Please explain

TOILET/HYGIENE SKILLS

Please check all that apply

Uses toilet independently

Uses toilet with supervision

Needs Assistance

Please explain

Follows a schedule

Please list times

Wears diaper/pull ups

Please give an special instructions

Has bladder issues

Please explain

Please share any signs or gestures that your camper may give to indicate his/her need to be changed or go to the bathroom:

BEHAVIORAL SKILLS

Behavioral concerns:

Please share about any behaviors of which we should be aware. Specify what the behavior looks like (screaming, dropping, biting, scratching, etc) rather than giving general descriptions (angry, upset)

When do these behaviors typically occur?

Are they more likely to occur with a specific gender?

If yes, which gender?

Check all that apply:

Self-injurious/Self-aggressive

Please explain

Tantrum

What behaviors does this include?

Aggression

What form does this take (hitting, biting, etc)?

Property destruction

(throws, breaks, slams objects)

Non-compliance

Please explain

Running away

Please explain

Difficulty with transitions

Please explain

Unusual interest in sight, feel, sound, or smell of things

Please explain

Behavior Modification Plan: Please explain, in detail, the behavior management plan that is being used at home and at school to modify inappropriate behavior. Our goal is to maintain consistency in the implementation of this plan and to work with you in this process

What is your camper's response to separation?

What is your camper's response to playing with other kids?

What activities, games, or toys does your camper enjoy?

What are some positive activities, games, statements, or actions that are helpful to reinforce good behavior in your camper?

Thank you for helping us create the best environment for your camper. Your information about your camper will help us prepare the rooms and space we need for all of our campers!

ADDITIONAL INFORMATION

Would you be interested in speaking with a representative from camp prior to the start of camp concerning your child?

Day and time best for you:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Which week will your camper attend? *