Full Name
*
Your Email
*
Form ID
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What is your child's age?
*
What is your child's diagnosis?
*
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Select your current Regional Center
Is your child currently enrolled in the Self-Determination Program?
Yes
No
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Will your child be attending a non-school-related camp, class, or social program at any point this summer?
Yes
No
Is there something that keeps you from sending your child to a camp or social program?
I would send my child if they had a 1:1 aide
I would send my child if I could arrange for proper transportation
I am not interested in sending my child
I would send my child if I had additional financial support
Other
Send with Aide
Send with Aide
Send with Transport
Send with Transport
Send with additional financial support
Send with additional financial support
Not interested in sending my child
Not interested in sending my child
Send Other reason
Paid by Regional
Paid by Regional
Paid out of pocket
Paid out of pocket
Paid Other
Paid Other
Paid Other comments
How do you pay for this camp for social program?
This camp or social program is paid or partially paid for by Regional Center.
We pay out-of-pocket.
Other
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Does your child receive Extended School Year (ESY) services?
Yes
No
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Legal Guardians (parents) work and schooling?
All legal guardians work or attend school (full-time or part time).
At least one legal guardian is a full-time caretaker of my child.
Other
All Guardians work or attend school
All Guardians work or attend school
Full time guardian caretaker
Full time guardian caretaker
Work Other
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Does your child receive Respite Services (hours) from Regional Center?
Yes
No
Are you receiving additional respite hours this summer from Regional Center?
Yes
No
How many additional monthly hours are you receiving?
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Does your child receive Specialized Supervision or Daycare services funded by Regional Center?
Yes
No
Are you receiving additional specialized supervision hours this summer from Regional Center?
Yes
No
How many additional monthly hours are you receiving?
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Does your child receive Behavioral Therapy services funded by Regional Center?
Yes
No
Are you receiving additional behavioral therapy hours this summer from Regional Center?
Yes
No
How many additional monthly hours are you receiving?
Does your child have a Behavioral Intervention Plan in their IEP?
Yes
No
Do you have concerns about your child’s behavior and/or does it affect their daily life?
Yes
No
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