Franklin Educational Services

  • Summer Camp Registration

    Register your child for our 1:1 supportive summer camp and help us ensure a safe, successful experience for every camper.

  • Student Information

  • Parent / Guardian Information

  • Format: (000) 000-0000.
  • Would you like to add an Additional Contact?
  • Format: (000) 000-0000.

  • Funding Information

  • Does your student receive funding for our services?

  • Toileting Readiness

    Camp staff may provide verbal reminders, but cannot assist with wiping, changing, or diapering.
  • Is your child potty trained for urine and bowel movements (daytime)?*
  • My child can independently (check all that apply):*
  • Accidents in the last 30 days:*
  • Does your child wear pull-ups during the day?*

  • Elopement / Bolting / Leaving Supervision

    Even indoors with 1:1 support, bolting toward exits can be unsafe.
  • Has your child ever bolted/ran from an adult or attempted to leave supervision?*
  • In the last 3 months, has your child attempted to leave a supervised area (classroom, building, playground, store, etc.)?*
  • When an adult says “STOP” or calls your child’s name, does your child reliably stop/return?*
  • When dysregulated, my child is most likely to (check all that apply):*
  • What helps prevent running/wandering? (check all that apply):*

  • Aggression Toward Others

    Safety: Aggression Toward Others
  • In the last 6 months, has your child harmed or attempted to harm others?*
  • If yes, check all that occurred:
  • In the last 30 days, frequency:
  • Severity history (check any that apply):

  • Self-Injury / Dangerous Behavior

    Safety: Self-Injury / Dangerous Behavior (Required)
  • In the last 6 months, has your child engaged in self-injury or dangerous behavior?*
  • If yes, check all:
  • In the last 30 days, frequency:

  • Property Destruction / Unsafe Throwing

    Episodes involving unsafe throwing or major property destruction.
  • In the last 6 months, has your child had episodes involving unsafe throwing or major property destruction?*
  • If yes, check all:

  • Support Snapshot

    Helps us set your child up for success.
  • Communication style:*
  • What helps most (check all that apply):*
  • Does your child require 1:1 support in other settings (school/community)?*
  • Has your child ever been asked to leave a program due to safety?*

  • Requested Schedule

    June 15th - August 28th
  • Requested Weeks (Must pick at least 2 consecutive weeks)

  • REFERRAL INFORMATION

  • Parent / Guardian Attestation

    Please initial each line to confirm your understanding and agreement.

  • I attest that the information above is accurate to the best of my knowledge.   
    I understand camp is 1:1, but it must remain safe for my child and our staff.   
    I understand camp requires independent toileting (no wiping/diapering/changing assistance).  
    I understand the camp may request early pickup if safety cannot be maintained despite supports.  
    I understand that children with high-risk bolting/elopement, severe aggression causing injury, or severe self-injury may not be appropriate for this setting even with 1:1 staffing.   
    Parent / Guardian:      

  • Date Signed
     - -
  • Should be Empty: