School Report for Elks Camp Grassick
This form is to be completed by the child's classroom or special education teacher. This report is for Elks Camp Grassick use only.
What camp session is this child applying to?
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3 Week Camp
2 Week Camp
Companion Camp
Identifying Information
Name of Child
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First Name
Last Name
Birthdate
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-
Month
-
Day
Year
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Gender
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Male
Female
Please define and describe this child's diagnosis, disability, or special need.
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Present School Attending
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Will the child attend this school next year?
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Yes
No
If no, where will they attend?
Name/Title of Person Completing this School Report
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Are you the Child's teacher?
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Yes
No
Name of Child's teacher
Address of School
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Classroom
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Grade
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Principal's Name
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School Phone Number
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Please enter a valid phone number.
Teacher's Phone Numbers
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Teacher's Email
example@example.com
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Personal Care Information
Level of Supervision Needed for Each:
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Independent
Supervision
Minimal Assist
Total Assist
Eating
Mobility
Toileting
Washing Hands
How would you describe the student's general hygiene and grooming skills?
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Does this child wear an incontinence product at any time?
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Yes
No
Does this child have any special dietary needs?
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Yes
No
If you answered yes to either of the previous 2 questions, please explain.
Is this child receiving any of the following services in the school or in the community?
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Speech/Language Therapy
Occupational Therapy
Physical Therapy
Reading Intervention
Counseling
Other
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Social and Emotional Information
Personal Traits: Please describe this child's maturity level, self-esteem, and level of independence in the school environment.
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Discipline: Are there any discipline or behavior management programs currently being used in the school that seem to work well with this child?
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Social: Is there a social curriculum that the child is receptive to? Is a reward system or consequence used?
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Motivation: What encourages this child to complete school work or change a behavior?
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Attitude Toward School: Does this child have any specific likes or dislikes? How is he/she affected by change of routine?
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Attention Span: What hold attention? Tips on redirection?
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Relationship to Authority Figures: How does this child respond to direction or rules? Is there anything that works well or does not work?
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Relationship to Peers: How does this child relate to peers? What kind of relationship does the student have? Are they consistent with those of same age peers? Do they relate to children older or younger?
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Does this child have any repetitive behaviors, stims, or tics?
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Yes
No
Please describe this child's repetitive behaviors, stims, and/or tics?
Does this child have any behaviors, periods of dysregulation, or physical outbursts?
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Yes
No
What sets off this behavior? Is there anything that escalates the behavior?
What does the behavior look like?
How long does a behavior typically last?
How often does the child exhibit these behaviors?
Is there anything that deescalates the behavior? What calms him or her down?
Are there any behavior plans or therapeutic practices that work with the child that we should continue at camp? If a behavior plan is in place, please attach.
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Upload Behavior Plan Here.
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Please list a few hobbies or interests of this child.
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How easily do you feel that this child could adjust to being away from home and in a camp environment.
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How do you feel this child will adjust to living with 5-8 cabinmates?
At camp, there is a very full schedule of activities and lots of sensory input (activity, noise, changing weather, etc.). Do you believe this child is able to keep an active pace for the entire camp session? Do you feel that they will be able to self-regulate with all the external stimuli?
Is there any other additional, pertinent information about this child that you feel would be helpful to Camp Grassick?
Upload any other pertinent information here.
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