Accommodations / Additional Support Information: Child's Profile
Roots 2 Rise Outdoors 2024
Person completing this form:
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First Name
Last Name
Relationship to child:
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By signing below, I consent to the information provided being collected, stored, and used by Roots 2 Rise Outdoors. The information will be provided to Roots 2 Rise Outdoors educators and will be securely stored in both digital and physical formats. A physical copy will be kept on-site for access. In the event of an emergency, Roots 2 Rise Outdoors may be required to share this information with the appropriate first responders to ensure the safety and well-being of the children under our care.
*For additional information about Roots 2 Rise Outdoors privacy policy please refer to our parent information package. For any additional questions please contact Robyn Broudie at info@roots2riseoutdoors.com
Signature
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Child's Name:
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First Name
Last Name
Experience with Roots 2 Rise:
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New to Roots 2 Rise
Returning to Roots 2 Rise
Diagnosis/Diagnoses:
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Please complete the following sections and provide as much detail as possible. This information will help us create a supportive environment for your child.
Please check all items that apply to your child and thoroughly explain checked answers.
Physical limitations:
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Yes
No
If yes, please explain:
Devices used:
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Walker
Wheelchair
Hearing Aids
Cochlear Implant
Augmentative and Alternative Communication Device
None of the above
Other
Details about device(s) and use:
Child's likes (favourite characters, movies, games, music, etc.):
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Child's dislikes (sounds, smells, touch, movement, foods, phrases, etc. that may upset your child):
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Does your child receive one-to-one support at school?
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Yes, full time support
Yes, part time support
Yes, on an as needed basis
No
If yes, please describe the one-to-one support your child receives:
Does your child respond better to male or female staff:
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Male
Female
Either
Please describe any further details about this:
Does your child have a safety plan at school?
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Yes
No
If yes, please describe what the safety plan is for and any important details:
Daily Routines
Please describe your child's skill level:
Toileting
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Independent
Independent with reminders
Partial Assistance
Complete Assistance
Other
If not independent, please provide more details:
Dressing
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Independent
Independent with help for fasteners (i.e., buttons/zippers)
Independent with prompting
Partial Assistance
Complete Assistance
Other
If not independent, please provide more details:
Eating
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Independent
Needs containers/packages opened
Needs reminders to eat
Partial Assistance
Complete Assistance
Other
If not independent, please provide more details:
Any other specific daily routines or specific accommodations needed:
Regulation
Please describe what it looks like when your child experiences different emotions and/or dysregulation.
When my child gets anxious, she/he:
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When my child gets excited, she/he:
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When my child gets frustrated, she/he:
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When my child is angry/upset, she/he:
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My child is sensitive to:
Sounds i.e., loud / unexpected sounds, background sounds, singing etc.
Visuals i.e., changes in light, sunlight
Touch i.e., fabrics/textures/tags, being touched unexpectedly, being wet / dirty
Smells i.e., perfumes, foods
Food i.e., smells / sight / taste of non preferred foods
Balance
Awareness of body position / movement
No sensitivities
Other
Describe these sensitivities:
My child exhibits the following behaviours:
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Runs away
Hits or punches
Kicks
Screams
Pushes or shoves
Scratches or bites others
Spits
Pulls others hair
Throws objects
Touches others inappropriately
Threatens others
Scratches, bites, or hits self
None of the above
Other
When do these behaviours occur (what are the potential triggers):
These behaviours typically occur towards:
Adults
Peers
Self
Those who they are upset with
Others in the nearby vicinity
Other
Please provide any other details about these behaviours:
What strategies do you use to support your child at home i.e., calming strategies:
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Communication
My child communicates by:
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Full sentences / no difficulty getting their message across
Single words
Gestures / body language
Sign Language
Alternative and Augmentative Communication Device*
Scripting (repeating words/phrases/sounds from others i.e., TV shows)
Other
Please describe how your child communicates:
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*Will your child be bringing their communication device to our program?
Does your child:
Make requests for basic wants and needs?
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Independent
With help
Not yet
Converse with peers/adults?
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Independent
With help
Not yet
Follow non-verbal directions i.e. pointing?
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Independent
With help
Not yet
Follow verbal directions within familiar routines?
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Independent
With help
Not yet
Follow verbal directions within new activities/environments?
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Independent
With help
Not yet
Utilize visual supports to follow directions i.e., visual schedule?
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Independent
With help
Does not use
Require processing time to follow directions?
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Yes
Most of the time
Some of the time
No
Emotional Development
Does your child:
Request a break when upset?
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Independent
With help
Not yet
Express feelings?
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Independent
With help
Not yet
Request help?
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Independent
With help
Not yet
Accept help?
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Independent
With help
Not yet
Indicate likes/dislikes?
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Independent
With help
Not yet
Respond to praise?
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Independent
Responds negatively
Does not typically respond
Social Development
Does your child:
Transition between activities?
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Independent
With help
Not yet
If needed, what strategies help with transitions (switching between activities) i.e., time warnings:
Recognize personal belongings?
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Independent
With help
Not yet
Make choices?
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Independent
With help
Not yet
Wait when directed?
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Independent
With help
Not yet
Stay with the group?
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Independent
With help
Not yet
Previous experiences in group settings (what groups your child has attended, how it went, successful strategies from the past):
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What is your child's comfort level with group activities:
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What is your child's preferred social interactions i.e., virtual, one-to-one with peer, small groups:
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Please add any comments you feel staff should know and areas of concern for supporting your child at our programs. The more information we have, the better prepared we can be to ensure your child has a positive experience.
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