LIFE SKILLS DEVELOPMENT,
RECREATION THERAPY AND TRANSITIONS
2015SUMMER PROGRAM APPLICATION
Please note that submitting an application does not guarantee acceptance.
Individuals will be contacted regarding the status of their application.
Please refer to our summer brochure to review program descriptions and application deadlines.
Section A – Application to programs Check only the program(s) you wish to apply to:
Programs for children ages 7-14 / Programs for youth ages 15-18(up to 21 if still inhigh school)
Out & About Club
Busy Bodies 1
Busy Bodies 2
Fun with Friends
Camp Connection
Access Boom Sailing / Making it Happen
Turning Point
The Independence Program (TIP)
Summer in the City
Youth@Work1
Youth@Work 2
Access Boom Sailing
Section B – General applicant information
Last name: / First name:Address (#, Street, Unit #):
City/Town: / Province: / Postal Code:
Gender:
Male Female / Date of birth (dd/mm/yy): / Telephone:Please provide a number we can reach you during the day time or where we can leave a message.
()
Have you participated in one of our programs before? No Yes
If yes, please write the names of the programs:
Section C – Description of disability/health condition
Name of disability/healthcondition (diagnosis) / Do you have any other diagnoses?Learning disability
Vision loss
Hearing loss
Other (please specify)
How do you/your child communicate?
Verbally
Alternate method (please specify) / Do you/your child require assistance with personal care?
i.e. toileting, feeding
No Yes
Assistive devices
None
Walker
Manual wheelchair / Power wheelchair
Scooter
Other, please specify
Weight: / Height
Do you/your child require 1:1 assistance/ supervision to participate in activities?
No Yes If yes, Please explain the type and frequency of support required:
Please note that 1:1 support (medical or behavioural) is not provided for these programs. In some programs we can accommodate a 1:1 worker but it in all cases it is the participant’s responsibility to schedule and pay for the worker.
Section D – Goals
Why do you/your child want to attend this specific life skills or recreation program?Please list 1 or 2 specific goals related to the program.(examples: skills you would like to learn, experiences you want to have)
Section E – Applications for Camp Connection only (ages 7-14)
This program is an introduction to overnight camp.Has your child attended an overnight camp program on their ownin the past? No Yes
Please note that Camp Connection camp grounds are not wheelchair or walker accessible.
If you are interested in a camp that is physically accessible please contact us for more information.
Section F–Applications for youth (ages 15-18up to 21 if in high school)
Are you currently in school?
Yes, High School
Current Grade:
Is this your last year? No Yes
Name of school: / Type of courses:
Applied or college preparation
Academic or university preparation
Mix of applied & academic (college/university)
Open
Workplace preparation
Youth@Work participants are required to travel to/within Toronto for work placements in the area south of Finch (to Lakeshore) and between McCowan (Scarborough) and Kipling (Etobicoke).
Are you able to travel to/within Toronto to participate in work placements?
No Yes
Section G – Applications for Residential Programs (ages 15-18 up to 21 if in high school)
(The Independence Program and/or Turning Point)
Please describe the type of care you will require. Be specific (i.e. transfers, toileting, feeding) + include the amount of time needed. / What are your goals in the next 2 years related to:School:
Career:
Independent Living:
Section H – Referral source - How did you hear about our programs?
Flyer in mail
Recreation, Respite &
Life Skills Fair / From friend/family
Holland Bloorview service provider
School / Holland Bloorview web site
Facebook or twitter
Other, please specify
Section I: Verification and signature
I verify that the information that has been given in this application is complete and accurate to the best of my knowledge.Applicantsignature: / Date (dd/mm/yy):
Please return this form to:
Holland Bloorview Kids Rehabilitation Hospital | Participation & Inclusion
Attention: Sandy Kinsella | 150 Kilgour Road, ON M4G 1R8
Tel: 416.425.6220 x3503 | Fax: 416.422.7037
The personal information you give us on this form helps us provide you with services at Holland Bloorview. We collect, use and share this information under the authority of the Public Hospitals Act.If you have questions, please contact the privacy office at 416-425-6220 ext. 3467 or .
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