Name:
Address:
City:
State:
Zip:
County:
Home Phone:
Cell Phone:
Work Phone:
*** Please be sure to include all phone numbers so we can reach you if needed***
Email:
Please answer the following questions:
Name of Individual with a disAbility:
Age:
Type of disAbility:
If you use a wheelchair is it power or manual?
Does he/she need a companion? (circle one)
Will you need materials in an alternative format? (circle one)
If yes please explain:
*** Requests for alternative formats must be made within a timely manner***
Are there any dietary restrictions that we need to consider? (circle one)
If yes please explain:
*** Requests for dietary restrictions must be made within a timely manner***
Siblings/Companions attending: (please give ages of siblings)
Are you a service provider or a teacher for individuals with disAbilities?
Agency or school name:
Arrival Date:
June 8, 2012
June 9, 2012
June 10, 2012
Departure Date:
June 10, 2012
Please let us know if you will be eating the following meals on Friday and Sunday:
Dinner Friday
Camper Info
Name:
Age:
Email:
DisAbility:
Allergies:
Medications:
Special Diets (diets will be provided by parents):
Other Medical Considerations:
***If you answer yes to any of the following questions, please provide a detailed explanation.***
Does your child need one-on-one support?
If yes please explain:
If yes, do you have a volunteer preference?
Does your child require assistance with toileting?
If yes please explain:
Does your child run away?
If yes please explain:
Please provide any additional information you would like to share about your child. This information helps us to be better prepared and ensure your child’s needs are met during camp.
***If your child is on the autism spectrum, please complete the following.***
Please describe your child’s needs and existing accommodations for each:
Communication style and systems (Does your child use the Picture Exchange Communication System? How do you understand your child’s needs and wants?)
Social Interactions:
Stress Triggers:
Repetitive Behaviors
Behavior Management Techniques
Calming Activities
Motivation or Reinforcers:
Special Interests:
Camper Registration Family Form Update - Please print the names for camp name badges of all those attending camp and check appropriate selection:
Check here to opt out of inclusion in our Network Contact List:
Please note: Due to updated security and safety policies for Children's Harbor, all children/family members under the age of 18 will be considered as "campers" and are required to participate in all planned age-appropriate activities. No one under the age of 18 may be unattended on the Children's Harbor campus at any time. Thank you for your consideration.By submitting this registration I understand that due to recent revisions in safety and security toys such as bicycles, tricycles, big wheels, skates, skateboards, razors, etc. will no longer be permitted at Children's Harbor. All children of volunteers and/or presenters will be required to participate full time in a regularly planned age-appropriate group activities. No child under 18 years of age may be unattended at any time. Thank you!
Total Cost is $30.00 per person. To secure a place , please make checks payable to:
The Full Life Ahead Foundation
*We Accept VISA, MasterCard & American Express
By submitting this registration, you are agreeing to allow The Full Life Ahead Foundation to use pictures and videos of you or your family in publications or on our website/ newsletter unless you opt out.
Registration Deadline May 11, 2012 (based on availability after this date)
For more information call 205-439-6527 or 205-222-1969
YOUR TIMELY REGISTRATION IS
VITAL SO THAT WE CAN PLAN MEALS
AND CABIN ASSIGNMENTS — WE
WANT YOU TO FEEL WELCOMED.
