Adult Day Camp Application

Adult Day Camp APPLICATION

A Division of 3 Bluebirds Farm ( revised 01/2026)
We encourage the applicant to complete this form as independently as possible, as it helps us get to know their voice, interests, and goals directly. Support is welcome if needed, but responses should reflect the applicant’s own perspective.

Before continuing with this application please keep in mind that we operate on a working farm. We will often times be outside with our animals, working in the garden, and exposed to various allergens. If you have an extreme aversion to spending time outside, an extreme fear of animals, or extreme allergies, please think twice before continuing with this application.

Please note that submitting an application does not guarantee acceptance — this is a review-based application process, and all participants must meet our eligibility criteria.
How did you hear about us?

Internet AdSocial MediaWebsite3BBF Program ParticipantOther
Your Name (applicant):*

First NameLast Name
Your Preferred Name:
Are you your own guardian?*

YesNo
Date of Birth*

MonthDayYear
Date
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
Choose all sessions you are applying to attend:*

SESSION 1: 9/8/2025 - 9/19/2025SESSION 2: 10/27/2025 - 10/31/2025SESSION 3: 12/1/2025 - 12/12/2025SESSION 4: 2/2/2026 - 2/6/2026SESSION 5: 3/2/2026 - 3/6/2026SESSION 5: 3/9/2026 - 3/13/2026Session 5: 3/16/2026 - 3/20/2026SESSION 6: 6/1/2026 - 6/5/2026SESSION 6: 6/8/2026 - 6/12/2026
What pronouns do you go by?*

He/him/hisShe/her/hersThey/them/theirs
Please upload a recent picture of yourself: *

Browse Files

Cancelof
Your Current Age:*
Living Arrangements:*

AloneParent(s)RelativeRoomate(s)Other
Your address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of adult legal guardian/custodian (IF APPLICABLE):

First NameLast Name
Phone number of adult legal guardian/custodian (if applicable):

Area CodePhone Number
Email of adult legal guardian/custodian (if applicable):
example@example.com
Please provide the contact information for the party responsible for financial payment for applicant's day programs/activities:
Name of the party responsible for payment*

First NameLast Name
Email of the party responsible for payment*
example@example.com
Phone Number of the party responsible for payment*

Area CodePhone Number
Candidate Criteria to Attend Adult Day Camp

Diagnosis & Support Needs*

	YES
Does not require a 1:1 aide
Does not eat inedible objects (Pica)
Ability to participate in activities without disruptive behaviors that interrupt the event with no active aggression or risk of elopement.
Willingness & ability to participate in group activities that require conversational skills
Is able to follow verbal directions
Is able to verbalize wants and needs
Independence in all daily living skills (toileting, eating, dressing)
Ability to remain in open space without wandering or running
Applicant must have a documented diagnosis of Autism Spectrum Disorder (ASD)
Applicant is able to function with minimal support in a small group setting (1:4) ratio.

Age & Eligibility*

	YES
Is 18+ (high school exit or transition-age adults)
Able to self regulate with support and willing to participate in structured froup activities.
Applicant must be interested in building social, vocational, and life skills in a naturalistic setting.

Communication, Literacy & Participation*

	YES
Has basic receptive and expressive communication skills (verbal or supported)
Demonstrate the ability to write & spell for journaling, worksheets, and written components of the curriculum (independently or with support)
Shows a willingness to participate in group discussions and role playing, farm tasks (gardening and animal care), and activities such as games, crafts, or cooking, etc.

Curriculum Alignment*

	YES
Applicant is actively working on (or interested in working on) skills like..initiating conversations, maintaining friendships, handling teasing/conflict, and appropriate digital communication.
Able to engage with structured lessons and social coaching
Open to learning in a supportive, guided social environment that includes written reflection and behaviorial rehearsal

Physical & Environmental Fit*

	YES
Able to navigate outdoor spaces (farm terrain, garden beds, animal pens).
Tolerant of sensory inputs common on a working farm (smells, sounds, textures).
Independently able to manage basic personal hygiene and self-care

Comments?
Have you attended any 3 Bluebirds Farm activities before?*
What are your your interests?*
What are your strengths and talents at home and in the community?*
What do you hope to achieve from the Adult Day Camps at 3BBF?*
What causes stress for you?*
How do you react when you are stressed? (for example, do you shut down, melt down, stem, etc).*
What is the best way that we can help you when you are stressed?*
What do you most admire about yourself?*
If you had an hour of free time, how would you most likely use that time?*
Are you shy, sensitive or nervous about anything we should be aware of?*
What concerns (if any) do you have about participating in the Adult Day Camps?*
Please write down anything else you'd like us to know about yourself to help make your involvement in the Adult Day Camps be a successful experience.*
Do you have seizures of any kind? If yes, please let us know the type & frequency. (If none, type "none"):*
Disabilities/Limitations besides autism (If none, type "none"):*

Are there any unusual family circumstances that make Adult Day Camps especially important for you?*

	Often	Sometimes	Not At All
Hyperactive
Learning Disabilites
Nightmares
Sexually Acting Out
Steals
"Meltdowns"
Lying
Withdrawn

Please elaborate on any of these selections above or add anything else we may have missed:
Your Signature (applicant)*

Clear
Applicant's Name*

First NameLast Name
Date*

MonthDayYear
Date
(IF APPLICABLE) Signature of Legal Adult Guardian/Custodian

Clear
Adult Guardian/Custodian's Name

First NameLast Name
Date

MonthDayYear
Date
Enter the message as it's shown*
Should be Empty:

Adult Day Camp APPLICATION

Please provide the contact information for the party responsible for financial payment for applicant's day programs/activities:

Candidate Criteria to Attend Adult Day Camp