4RKids Foundation
Sensory Friendly summer camp
participant application
Date of application: ______
Individual’s Name: ______
NICKNAME OR PREFERRED NAME______
Birthday: ______Age: ______
Diagnosis or Symptoms: ______
Parent or GUARDIAN Name: ______
Address (street, city, zip): ______
______
Home Phone: ______Cell Phone:______
E-Mail: ______
How can we contact you while your child is at camp?
Phone # A: ______type (mobile, pager, etc.): ______
Phone # B: ______type (mobile, pager, etc.): ______
How did you hear about the summer camp? ______
______
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In the event of an emergency, the following person may be called and is authorized to PICK UP THE CHILD (if under 18 or if under guardianship)
Positive identification must be provided before your child(ren) will be released.
Name: ______Relationship: ______
Phone Number: ______
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Doctor’s Name: ______Hospital Pref.: ______
Phone Number: ______or ______
Other emergency contact:______Phone Number: ______
Page 2, 4RKids Summer Camp Application
1. Activities - Please be as specific as possible
Activities my child likes: (music, stories, coloring, painting, physical games, independent play, group
activities, reading, being read to, etc.) ______
______
______
______
My child needs encouragement to: ______
______
______
______
My child does not enjoy: ______
______
______
______
Please don’t ask my child to: ______
______
______
______
My child is afraid of: ______
______
______
______
My child learns best when the teacher: ______
______
______
______
My child participates more when the teacher: ______
______
______
______
Page 3, 4RKids Summer Camp Application
2. Physical Needs
Vision: / Hearing: / Motor Ability:Normal / Normal / Normal / Crutches
Impaired / Impaired / Head Control / Braces
Blind / Deaf / Rolls Over / Walks
Hearing Aid / Sits / Wheelchair
Crawls / Walker
Cruises
Toileting Skills:
Toilets Independently
Needs Help Staff can help by: ______
Potty Trained, needs assistance
Currently being potty trained
Diapers: cloth disposables pull-ups
Eating Habits: *Please note, participants must bring sack lunch
No Restrictions
Allergies: Food: ______Other: ______
Can take nothing by mouth
Soft Foods only
Bottle only
Specific requests: ______
3. Communication with others
Communicates with others using:
Speech: words phrases sentences
Babbles
Gestures
Sign language
Other (describe): ______
Can understand what others say:
All of the time
Most of the time
Some of the time
Other: ______
Page 4, 4RKids Summer Camp Application
Behavior: (check all that apply)
Outgoing / ShyPlays in groups / Hyperactive and/or ADD
Adapts to new situations well / Adapts to new situations with difficulty
Responds to correction well / Responds to correction with difficulty
Is sometimes destructive / Sometimes threatens others
Sometimes hits, bites, or hurts self/others / Sometimes attempts to run away
My child responds to separation from his/her parents by: ______
______
My child is best comforted by: ______
My child lets someone know what he/she wants or needs by: ______
______
4. Special Medical Needs
My child requires the following medical equipment: ______
My child requires care from a nurse:
Never
Only when (please specify): ______
All the time
My child is taking the following medication: ______
Other medical information about my child: ______
5. Other things I’d like you to know about my child:
We have a pet, named: ______
Favorite color is: ______
Other dislikes: (example: dogs, loud sounds, certain food or activity): ______
______
if your child is struggling during an activity, at what point would we need to contact you? ______
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Staff Review: ______Date: ______
Scholarship Requested: NO YES If yes, amount awarded:______
Page 5, 4RKids Summer Camp Application
RELEASE FROM LIABILITY AND
AUTHORIZATION FOR EMERGENCY TREATMENT
In consideration of the undersigned child’s participation in the above program and to the extent allowed by Law, we hereby consent for said child to participate in the 4RKids Summer Camp program and hereby release said organization, and all of its officers, employees, paid and unpaid staff (volunteers), from any and all liability or any kind or character arising out of said child’s participation in such program and its activities, or any accident, illness or injury resulting therefrom, and agree to indemnify and hold harmless the organization and its officers, employees, paid and unpaid staff (volunteers) from and against any and all such claims, if any.
I (We) further consent for any adult leader of said activity to secure emergency medical treatment for my child which may be considered to be necessary in a situation in accordance with generally accepted standards with medical practices for the particular type or injury or illness involved.
This Release and Authority shall be valid and binding for the activity in which said child participates unless previously revoked in writing.
______
Child’s Name
______
Parent / Guardian Signature Date
Created 5/11/16
PHOTO PERMISSION SLIP
I, ______(name of parent/guardian), give permission for photographs (both digital and printed) and video, if applicable, of, ______(name of participant), to be used by 4RKids and their representatives for marketing and publicity for the organization from this date until revoked in writing.
______Signature (Parent or Guardian, if applicable) date
Created 5/11/16