2023 ACCESS Summer Club

ACCESS Summer Club

Registration Form
SUMMER CLUB DATES

Please indicate which dates your son/daughter is joining us:*

Week 1 | July 3rd - July 7th

1,000.00CHF

Week 2 | July 10th - 14th

1,000.00CHF

Week 3 | July 17th - 21st

1,000.00CHF

Week 4 | July 24th - 28th

1,000.00CHF

Enter coupon

Total

0.00CHF

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

GENERAL QUESTIONNAIRE

CONTACT DETAILS
Name of intern*

First NameLast Name
Date of birth*

MonthDayYear
Date
Postal address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Provide a copy of your son/daughter's identity card *

Cancelof
Provide a copy of your son/daughter's insurance details *

Cancelof
Provide a copy of your son/daughter's TPG card

Cancelof
Name of Parent/Guardian*

First NameLast Name
Parent Mobile Number*
Please enter a valid phone number.
Intern Mobile Number*
Please enter a valid phone number.
Parent/Guardian email address*
example@example.com
Is the intern is currently enrolled at ACCESS?*

YesNo
if yes, skip to the last page

if no, please fill in the information

GENERAL BACKGROUND
Mother tongue language (s)
Other spoken/written language(s)
Fluency of spoken/written languages
CLINICAL BACKGROUND
Diagnoses (if any)
Intern’s communication level. Please list any communication aids/ supports used.
Intern’ strengths (please list any skills or special interests)
Intern’s toileting routine, dressing routine and feeding routine (self-feed, etc.)

BEHAVIORS OF CONCERN
Does your son/daughter display any behaviors of concern?

YesNo
Please describe the behavior
When is the behavior most likely to occur?
When is the behavior least likely to occur?
Any sensory issues/triggers we should be aware of?
Does your son/daughter have difficulty coping with any particular situations?
Are there any specific triggers for these behaviors?
What strategies work well with your son/daughter?
What strategies have you used that have not been successful?

MEDICAL INFORMATION
For the safety of the intern and our team, we ask that you fill in this form as honestly and completely as possible. We will use the information to provide the best nurturing environment for your son/daughter
Any known medical condition (s) (e.g., allergies, epilepsy, asthma) Please ensure that we are supplied with written information on the course of treatment that should be adhered to while the individual is under our care.
Medication(s) currently taking (if any) - please provide doctor's prescription with the medication:
Known side effects of any medication(s) taken (if any):
Please indicate if the child may suffer from seizures (frequency)
Known triggers to seizures:
Is there any other information which we should know? Kindly please describe/tell us in the space below:

PERMISSION TO USE PHOTOS & IMAGES
ASK-All Special Kids may wish to use photographs and images from the programs undertaken as part of this collaboration. Any such images and photographs would highlight the participants either demonstrating learning techniques or participating in the ASK programs.

In accordance with ASK policy, the names of individual participants will not be released with photographs. This release form applies only to any educational publications and promotional materials published after 15 October 2012. I hereby authorise ASK to publish the photographs taken of me and/or the undersigned program participant, for use on ASK’s website and in any printed educational publications and/or general media releases.

I, {nameOf7}, release ASK from any expectation of confidentiality for the undersigned program participant and myself. I attest that I am the parent or legal guardian of the participant mentioned below and that I have the authority to authorise ASK to use their photographs and images. This release is valid from the date of signature until written notice is received from the parent/guardian revoking this Authorisation. I acknowledge that participation in publications and websites produced by ASK is voluntary, and neither the participant nor I will receive any financial compensation. I further agree that participation in any educational publications and website produced by ASK confers no rights of ownership whatsoever. I release ASK its owners, partners, volunteers, and employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned individual.
I agreeI do not agree
{nameOf}

{dateOf}

{nameOf7}
Date

MonthDayYear
Date
Parent/ Guardian Signature:

Clear
Intern's Signature:

Clear

EMERGENCY CONTACT DETAILS
Please fill in the following with the contact details of two individuals whom we should contact in case of an emergency.
EMERGENCY CONTACT 1
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to intern:
EMERGENCY CONTACT 2
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to intern:

CHECKLIST
Please review the checklist before you send us your form:

Completed the contact information and emergency contact detailsCompleted the general questionnaire and intern’s historyCompleted medical informationProvided us with your goals for your son/daughterSigned the photo permission formSubmitted any previous reportsProvided a copy of your identity cardProvided a copy of your insurance detailsProvide a copy of travel card (we will be using public transport and it is useful for individuals to hold a valid TPG travel card)
Should be Empty:

ACCESS Summer Club

SUMMER CLUB DATES

GENERAL QUESTIONNAIRE

PERMISSION TO USE PHOTOS & IMAGES

CHECKLIST