2025 Adaptive Summer Application

Adaptive Grow & Explore Summer Program
Select Program*

Youth Age 6-8Youth Age 9-10Youth Age 11-12Teen 13-15Teen 16-7
PERSONAL INFORMATION
Participant Name*
DOB*
Age*
Sex*
T-Shirt Size*
Street Address*
City*
Zip Code*
Parent/Guardian Name*
Parent/Guardian Name*
Email address*
example@example.com
Phone #*
Support Coordinator Name*
Email*
example@example.com
If you DO NOT wish to give photovideo permission please initial here
EMERGENCY CONTACTS
Name/Relationship*
Phone #*
Phone #*
Name/Relationship*
Phone #*
Phone #*
MEDICAL INFORMATION
Primary Diagnosis*
Other/Secondary*
Does the participants have any allergies?*

YesNo
If you answered YES please list known allergies*
Please describe procedure for care*
Does the participant utilize adaptive equipment: (AFO's/AAC Device)*

YesNo
If YES please list equipment*
Does the participant have known history of seizures?*

YesNo
If YES, please answer the following: Medication?*

YesNo
Last seizure date

MonthDayYear
Date
Please describe procedure to follow for care
NUTRITIONAL NEEDS
Does the participant have a food sensitivity and/or special diet?*

YesNo
If YES, please list *
PERSONAL CARE NEEDS
Interact well with others?*

NeverRarelyOccasionallyOftenRegularly
Is cooperative with peers and adults?*

NeverRarelyOccasionallyOftenRegularly
Express his/her needs?*

NeverRarelyOccasionallyOftenRegularly
Exhibit age-appropriate behaviors?*

NeverRarelyOccasionallyOftenRegularly
Hit or strike others?*

NeverRarelyOccasionallyOftenRegularly
Use of foul language?*

NeverRarelyOccasionallyOftenRegularly
Exhibit self destructive behavior?*

NeverRarelyOccasionallyOftenRegularly
Reacts aggressively to losing games?*

NeverRarelyOccasionallyOftenRegularly
Can the participant independently use the restroom?*

YesNo
Does the participant need verbal cues to use restroom?*

YesNo
If you answered YES please describe
Does the participant use diapers/pull ups?*

YesNo
NOTE: Participants must be physically independent to take care of bathroom needs.
Does your participant need assistance with eating?*

YesNo
If you answered YES please describe*
Does your participant have any visual impairments*

YesNo
If you answered YES please describe*
Does your participant have any hearing impairments*

YesNo
If you answered YES please describe*
Does your participant have any communication difficulties?*

YesNo
If you answered YES please describe*
Sensory: What kind of sensory experiences does participant avoid or seek?
Sound*

SeeksAvoid
Touch*

SeeksAvoid
Visual*

SeeksAvoid
Taste*

SeeksAvoid
Smell*

SeeksAvoid
Movement*

SeeksAvoid
PARTICIPANT ACTIVITY INTERESTS
Does your participant do well in small groups?*

YesNo
If you answered NO please describe
Does your participant do well in large groups?*

YesNo
If you answered NO please describe
Please select summer activities your participant are MOST interested in: (Please check all that apply)

SportsArtsAnimalsCookingVideo GamesMoviesMusicScienceField TripsLegosWater DaysPool
Knowing your summer participant is important to our staff! Please list any additional likes and dislikes of activities, TV interests, music, etc:
LIKES
DISLIKES
Please list any other information that would be important for our staff to know about your participant
Should be Empty:

Adaptive Grow & Explore Summer Program

PERSONAL INFORMATION

EMERGENCY CONTACTS

MEDICAL INFORMATION

NUTRITIONAL NEEDS

PERSONAL CARE NEEDS