3BBF Teen & Adult Farm Camp Questionnaire

Let us know the types of future teen & adult farm activities you would like to see us plan by answering the below questions. Please complete one survey per eligible individual. Thank you for taking the time to answer and help us develop our farm activities to meet your family's needs!

* Required
Your Name

First NameLast Name
Email*
example@example.com
What is the current age of the individual this survey represents?*
Gender of this individual*

MaleFemaleOther
What county of NC does this individual reside?*
Does this individual have a disability? (check all that apply)*

AutismPDDNOSADD/ADHDCognitive DisabilityPhysical DisabilityOther
How intense are this individual's needs?*

Has some minor needs (assistance, choice making, redirection, has no aggression at all)Has moderate needs (supervision, safety, mild behavioral, usually has no aggression)Has intense needs (medical, physical, behavioral, aggression, and/or safety)Other
If you selected "moderate" or "intense" above, please explain:
Does this individual have any ambulatory needs? (check all that apply)*

Uses a wheelchairUses walking aidsNeeds physical assistance on some terrain, steps, etc.Needs no ambulatory assistanceOther
Does this individual have any nursing needs? (check all that apply)*

Has seizuresNeeds medications administered during the dayIs tube fedNeeds blood glucose monitored regularlyHas acute medical needs: bee stings, food allergies, etc.No, we have no nursing needs at this timeOther
Please explain any other types of needs this individual may have in order to help us plan our activities.
What funding source(s) does this individual have available to them? (please check ALL that apply)*

Private PayNC Innovations WaiverSSDIAll of the aboveOther
Has this individual attended any type of day program or camp in the past?*

YesNo
If yes, please list the types of activities that were offered there:
If yes, please list this individual's preferred activities that were offered there:
Least preferred activities that were offered there?
Considering the future, what type of 3BBF activities might this individual be interested in as a teen or adult? (check all that apply)*

Teen Day Farm Camp (ages 13-22): Vocational, social & life skills, homemaking, recreation on the farm. Easing transition into adulthood. (JUNE & AUGUST ONLY).Adult Day Farm Camp (ages 18+): Building community connections, skills reinforcement, self advocacy, recreation on the farm. (NOT including June, July & August).Learning/work/volunteer experiences that lead to potential integrated community employment or potential internships/employment at 3 Bluebirds Farm.Take Flight Clubs (ages 13-22): Social clubs for individuals with low needs autism that meet routinely throughout the year to socialize.Take Flight Clubs (ages 23+): Social clubs for individuals with low needs autism that meet routinely throughout the year to socialize.
Other activities not listed above:
If this individual were to partake in any future 3BBF teen or adult day farm activities, how often would they choose to attend?*

Multiple 1-WEEK SESSIONS throughout the academic year, with opportunities for summer internships to practice skills on the farm when children's camps are in session.Multiple 2-WEEK SESSIONS throughout the academic year, with opportunities for summer internships to practice skills on the farm when children's camps are in session.Multiple 3-WEEK SESSIONS throughout the academic year, with opportunities for summer internships to practice skills on the farm when children's camps are in session.
Other option not listed above
What hours would they like to attend?*

Full Days (9am-3pm)Half Days (9am-12pm)Half Days (12pm-3pm)
Other option not listed above
Is there anything else you wish to share with us at this time to help us plan our teen & adult activities on the farm?
Thank you so much for taking the time to fill out our questionnaire! If you have any questions and would like to speak with us, please don't hesitate to give us a call at 919-629-7500 or email us at Hello@3BluebirdsFarm.org

Thank you!
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