School Report for Elks Camp Grassick

School Report for Elks Camp Grassick

This form is to be completed by the child's classroom or special education teacher. This report is for Elks Camp Grassick use only.
Identifying Information
What camp session is this individual applying to?

Therapy CampSkills CampMedical Respite CampRecreation Camp
Name of Applicant*

First NameLast Name
Birthdate*

MonthDayYear
Name/Title of Person Completing School Report:*
Student's Teacher (If different from person completing this report.)
Email Address of person completing this report and/or individual's teacher:*
Please define and describe this child's diagnosis, disability, or special need.*
Present School Attending*
Address of School*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Classroom*
Grade*
Principal's Name*
School Phone Number*
Please enter a valid phone number.
Will the child attend this school next year?*

YesNo
If no, where will they attend?

This individual is receiving or could benefit from: (Check all that apply)

	Is currently receiving services	Could benefit from this area while at Camp Grassick
Speech/Language Therapy
Reading Intervention
Occupational Therapy
Physical Therapy
Behavioral Intervention
Practicing Independence with ADLs
Assistance with Hygiene/Grooming
Practice in appropriate social skills and/or Social Emotional Learning
General Summer Camp Experience

This individual is receiving or could benefit from:

Speech/Language TherapyOccupational TherapyRemedial ReadingBehavior InterventionWorking on Independence with ADLsHelp with Hygiene/GroomingGeneral Camping ExperiencePractice in appropriate Social Skills and/or Social Emotional Learning
Information from Camp
I would like to receive a copy of the acceptance or non-acceptance letter and pre-camp information:*

YesNo
If this individual is accepted, I would like to receive a copy of the report and follow up information after camp:*

YesNo
How would you like to receive information from camp?

I would like to receive paper copies in the mail.I would like to receive digital copies by email.I would like to receive paper and digital copies.

	Independent	Supervision	Minimal Assistance	Moderate Assistance	Total Assistance
General Toileting
Toileting after bowel movement
General hygiene while at school such as keeping clothes tidy, wiping face after meals, etc.
Hair grooming
Mobility
Washing hands
Serving themselves food
Pouring beverages
Cutting food
Feeding themselves

Identifying Information