Camp Questionaire Form

Today's Date *

School District *

Child's Name *

Child's Birthdate *

Street Address *

City *

State *

Zip *

Phone Number *

Alternate Phone Number

Form Completed By

Relationship To Child

Diagnosis

Yes

Since?

Information Regarding Condition

Seizures

Yes

Since?

Information Regarding Condition

Medications

Yes

Since?

Information Regarding Condition

Allergies

Yes

Since?

Information Regarding Condition

Ear or Throat Infections

Yes

Since?

Information Regarding Condition

Birth History

Did the mother carry full term?

Yes

What weeks was the child born?

Birth Weight

Family Members:

Please list the names and ages of all persons living at home:

1. Name

Age

2. Name

Age

3. Name

Age

4. Name

Age

5. Name

Age

6. Name

Age

Sleep

Co-sleeping

Sleeps Through Night

Remains in Bed

Dietary

Allergies / Restrictions

Education

Is your child currently enrolled in a school program?

Yes

Name of School

City

Grade

Type of Classroom

Has your child ever been evaluated by a school diagnostic team?

Yes

What were the results

Does your child receive services through school?

Yes

Please describe their performance at school

Are there any academic challenges?

Yes

Developmental Milestones

Motor Skills
At what age (in months or years) did your child:

Belly Crawl

Feed Self

Crawl

Dress Self

Sit Unsupported

Bathe Self

Walk

Become Toilet Trained

Roll Over

Chew Solid Food

Do you have any concerns with Activities of Daily Living skills? (Eating, Dressing, Bathing, Grooming, Etc.)

Yes

Please Describe

Did your child use baby equipment? (Check all that apply)

Jumper

Bouncer

Swing

Bumbo Seat

How much time per day was equipment used? (Minutes or hours per day)

Concern(s) regarding fine motor skills

Concern(s) regarding gross motor skills

Sensory

Concern(s) regarding sensory

Speech and Language

At what age (in years or months) did your child:

Babble

Say first word

What was it

Combine words

Example

Speaks in Sentences

Are your child's words understood by others?

Yes

Are there any other languages spoken at home?

Yes

Are your child's sentences understood by others?

Yes

What languages

Social Skills / Play

Does your Child

Does your Child prefer to play with

Does your Child play with toys

What toys bring out the best in your child

Concern(s) regarding social skills/ play

Behavior

Does your child have tantrums, aggression, and/or self-injury that our camp staff should be aware of?

Yes

Concern(s) regarding behavior

Describe Behavior

Evaluations

Has your child been tested/evaluated for the following?

Occupational Therapy

When

Where

Diagnosis/Treatment

Speech-Language

When

Where

Diagnosis/Treatment

Vision

When

Where

Diagnosis/Treatment

Hearing

When

Where

Diagnosis/Treatment

Psychological

When

Where

Diagnosis/Treatment

Are there any precautions the camp staff should take when working with your child?

What do you hope to gain from Summer Camp? Please list any specific goals you would like to set

Please provide a copy of your child's IEP and / or clinical therapy goals and progress notes.

Parent Name*

Date*

I have read and agree to the terms and Conditions

* = Required Information