2023 Summer Camp Group Interest
Please complete this form so you can be added to the waitlist for summer camps!
Name of Child
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
How did you hear about us?
Social Media/Online search
Therapist referral
Better Together Newsletter
Physician Referral
School Therapist/Team
Other
Group Location - The following options are confirmed dates/times for each location. More days may be added depending on need.
*
Meridian (Wednesday)
Nampa (Monday/Tuesday/Wednesday)
Parma (Tuesday/Thursday)
Notus (TBD)
Best time for group - Exact group times are currently TBD based on space, location and therapist availability. Most group times will range from 1.0-2.0 hours long.
*
Morning
Afternoon
Either time
What age group are you interested in?
*
Preschool 3-4
Young child 5-7
Child 8-10
Pre-Teen 11-12
Dates not available - Due to high interest and limited availability, 80% Attendance rule will be enforced. Please let us know if there are dates you are planning on being gone to help our therapists better plan for the groups.
How does your child communicate?
Non verbal
Gestures
Single words
Short phrases
Sentences
Engages in conversations
Other
Diagnoses:
No diagnosis
Autism Spectrum Disorder
ADHD
Speech/Language Delay
Down Syndrome
Cerebral Palsy
Cognitive Impairment/Developmental Delay
Other
Challenges: Please check the following challenges that describe your child
Anxious
Withdrawn
Rigid
Impulsive
Verbally aggressive
Physically aggressive
Distracted/distracting to others
Oppositional
What do you hope to gain from the summer group?
Conversational skills (greetings, initiates, eye contact, engaging, staying on topic, interrupting)
Making friends
Play skills (turn taking, initiating, sustained play, following rules, sportsmanship)
Practice using or increasing Speech/Language Skills
Practice using or increasing Occupational Therapy Skills (Fine motor, sensory, etc)
Other
Caregiver/Parent Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to contact you
Email
Phone
Other
Participant Shirt Size
Small
Medium
Large
X Large
Submit
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