2017 First Steps Camp: Family Education and Experience Program

2017 First Steps Camp: Family Education and Experience Program

October 12th-15th, 2017

Family Application Information

1. The following members of our family will attend the First Steps Camp Fall 2017:

Name of Child using AAC system: ______________________________ Age/dob: ________________

(Easter Seal’s camp requires an RMV Application for all campers & siblings attending camp)

Sibling’s Name: ______________________________________________ Age/dob: ________________

(Easter Seal’s camp requires an RMV Application for all campers & siblings attending camp)

Mother’s Name: ____________________________________________

Father’s Name: _____________________________________________

Other: (School therapist, etc.) _______________________________

Home Address: _________________________ City: _______________ Zip Code: _____________

Home Phone: ___________________ Cell Phone: ___________________ email: _______________

1. For the child using an AAC system please answer the following questions:

● AAC System Used: ___________________________________

● System first acquired (date): ____________________________

● Where is this system used: ____school ____home ____ community

● What is this system used for most of the time; ____________________________

_________________________________________________________________

1. How well does your child use his/her system? __very well __ok __ not much

Please explain: ____________________________________________________

_________________________________________________________________

2. As parent(s) how well do you understand how to use your child’s AAC system:

__ very well __ ok __ not well Explain: ________________________________

________________________________________________________________________

3. What additional information would you like to know about your child’s AAC system:

_______________________________________________________________________

4. What do you want your child to know more about in using his/her AAC system:

________________________________________________________________________

5. Does your child use his/her AAC system with other members of your family (e.g., sibling, grandparents, aunts/uncles, neighbors, friends)? __ YES __ NO Explain:

________________________________________________________________________

6. As a family, what are the biggest challenges you face in using your child’s AAC system?

________________________________________________________________________

7. What are your goals for your child in the use of his/her AAC system?

________________________________________________________________________

8. What information or skills do you or your child need to make this happen?

_______________________________________________________________________

9. What are your goals for this First Steps Camp or what would you like to know at the end of this weekend? _________________________________________________________

________________________________________________________________________

10. Any additional information you would like to share or add to this application?

________________________________________________________________________

Please send this form with the additional enclosed information by September 8th, 2017 to:

Felicia Hardney, Administrative Service Coordinator
Children's Hospital Colorado

13123 E 16th Avenue, B030 ASL
Aurora, CO 80045

Email:

Child’s name: __________________________________________