Camp LOL, Girls' Club Application

Camp LOL, Girls' Club Application
Student First Name:
 
Student Last Name:
 
Gender:
Male
Female
 
Student Birthdate:
 
Which Saturday program are you registering for?
Camp LOL
Girls' Club
Camp LOL + Girls' Club
 
Child lives with:
Both Parents
Mother
Father
Other: Please specify at end.
 

PARENT/GUARDIAN 1 INFORMATION

 
First Name:
 
Last Name:
 
Relationship to child:
 
Street Address:
 
City:
 
State/Province/Region:
 
Postal/Zip Code:
 
Primary Phone Number:
 
Alternative Phone Number:
 
Email:
 

PARENT/GUARDIAN 2 INFORMATION

 
First Name:
 
Last Name:
 
Relationship to child:
 
Street Address:
 
City:
 
State/Province/Region:
 
Postal/Zip Code:
 
Primary Phone Number:
 
Alternative Phone Number:
 
Email:
 
Child's Current School:
 
Is your child in a special education program?
Yes
No
 
Does your child have a 1:1 staff support?
Yes
No
 
What kinds of related services, if any, does your child receive at school?
Occupational Therapy
Speech/Language Therapy
Aide in classroom
Pull-out Services
IEP
Other
None
 

Is your child currently taking any medications? If so, please list below including dose and time taken.

 

What is your child's current/most recent diagnosis?

 

Please list any of your child's significant health conditions.

 
Please list any of your child's allergies.
 
Please list any of your child's special diet/food restrictions.
 

Please describe any behavioral difficulties that your child has (e.g. hitting, biting, self-injurious behaviors, etc.). Please be specific. Withholding information may hinder our ability to handle any crises or challenging situations.

 

What are your child's likes and/or motivators?

 
Please check any additional services that your child receives outside of school:
Therapy (individual/group)
Psychiatrist/Medicating physician
Speech Services
Occupational Therapy
Social Skills Training
Other
None
 

What special interests and strengths does your child have?

 

What are your child's current areas of need or challenges?

 

Please add anything else you think we need to know about your child.

 
Click the button below attach a current picture of your child. Please add your child's name to the subject line. 
 

DIGITAL SIGNATURES

Parent Guardian 1

I hereby make an application for my child to attend the Ivymount Outreach Program. I have filled out all of the information to the best of my knowledge.

I realize that this is simply an application and that my child has not at this time been accepted to the Ivymount Outreach Program.

Please write your name below.

Date

This application requires a non-refundable deposit, please click the "Submit" button below to be taken to the payment page.

 



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