Day Camp information form
Please fill out this form with as much detail in it to help our Day Camp Counsslor provide your child with the best experience. Every child attending our day camp will need to have a completed form on file.
Name of child
*
First Name
Last Name
Does your child have a nickname they like to be called? What is it?
Age of child
*
Child's birthday
Parent Name completing this form.
First Name
Last Name
Parent email
example@example.com
How will you be paying for Day Camp?
Invoice me
I will pay at the Sensory Zone
I'm using respite hours for all
I'm using respite hours for partial payment and will pay the rest.
Does your child have CLTS?
Yes
No
If yes: Who is your Case Manager?
First Name
Last Name
Case Managers email
example@example.com
Case Managers phone #
Please enter a valid phone number.
What room or area of the Sensory Zone does your child LOVE the most? Click all that apply.
*
Gym
Calming Room
Toddler Zone
Touch wall area
Quiet Nook
Game Room
Outside fenced in area
What hobbies or interests does your child have?
*
What diagnoses (if any) does your child have?
*
How does your child communicate? Is there anything the day camp should know about your child's communication? (verbal, written, sign language, talk to text device, AAC device, etc..)
*
Please share with us ways to positively work with your child. What can a respite worker do to ensure your child has a good experience? Does your child have any positive coping skills that they use or like to use?
*
Please share with us ways that the day camp worker should not work with or communicate with your child? What does your child NOT like?
*
Does your child require assistance with any of the following:
going up or down stairs
putting on or tying their shoes
opening snacks or drinks (provided by parent, no peanut products please)
transitioning from wheelchair to foam pit, trampoline, crash pad or swing)
bathroom assistance (if clicked, please explain below)
Does your child have any allergies? If so, to what?
*
Will your child need to take any medication while at the Sensory Zone? All medications will need to be in original bottle with full instructions and kept at the front desk during respite.
Yes
No
What type of medication may your child need to take while at the Sensory Zone? All medications will be administered by lead staff on site that day according to instructions provided.
Which of the following can the staff at the Sensory Zone adminster to your child?
ice pack
tylenol (childrens)
basic medical attention (scratches, bumps, bruises)
cough drop
popsicle for sore throat
Emergency medical attention by training professional (if needed) Guardian will be called if anything happens requiring medical assistance.
If you clicked bathroom assistance, what assistance would they require?
What else would you like the respite worker know about your child?
*
Other infomation not asked for that you feel is important:
*
Parent #1 Information
First Name
Last Name
Phone Number:
Parent #2 Information
First Name
Last Name
Phone Number:
Emergency Contact person (non guardian to contact in case of an Emergency)
*
First Name
Last Name
Emergency Contact phone #
*
Please enter a valid phone number.
Whi IS allowed to pick up the child?
Whi is NOT allowed to pick up the child?
I allow the Sensory Zone to take pictures of my child engaged in activities for Sensory Zone marketing purposes? (If yes, please sign)
I allow the Sensory Zone to take my child out of the Sensory Zone on a walking/driving field trip if provided all the details prior to the field trip? (If yes, please sign)
Signature of parent/guardian completing this form.
Submit
Should be Empty: