2026 Adaptive Summer Camp Application

2026 Adaptive Summer Camp Application Form

Please fill out the form below. Contact rmbrown@saltlakecounty.gov with any questions.
Participant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Parent/Guardian Name *this is who will be contacted regarding camp**

First NameLast Name
Parent/Guardian Email *this is who will be contacted regarding camp**
Parent/Guardian Phone Number *this is who will be contacted regarding camp**
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1st Emergency Contact Name*

First NameLast Name
1st Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
1st Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Emergency Contact Name*

First NameLast Name
2nd Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
2nd Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List Name, Relationship to participant, and phone number of persons allowed to pick your child up from camp.*
If there is/are specific person(s) NOT allowed to pick your child up from camp, please list their name and relationship to your child.

Activity Assessment*

Rows	No Interest	Neutral	High Level of Interest
Sports/Fitness/Outdoor Activities
Arts & Crafts
Social Activities/Games
Music/Dance/Drama
Willing to participate in new activities

Social Assessment*

Rows	Almost Never	About Half of the Time	Almost Always
Is easily understood when talks
Makes needs known with words
Makes needs known with gestures
Is appropriate with others in a group setting

Rows	Almost Never	About Half of the Time	Almost Always
Is appropriate with the general public
Shares things (objects. toys. etc.) willingly
Takes turns willingly
Respects the space and property of others

Emotional Assessment*

Rows	Almost Never	About Half of the Time	Almost Always
Feels Good About Self
Expresses Emotions
Handles Frustration Well
Handles Disappointment Well
Handles Anger Well
Expressions/Behavior Matches Emotion

Cognitive Assessment*

Rows	Almost Never	About Half of the Time	Almost Always
Follows direction on first command
Follows more than one direction at a time
Engages in appropriate conversation (not just commands)
Makes choices between 2 alternatives
Makes choices between 3 alternatives
Engages self in activities provided for them
Stays on task for more than 15 minutes by self

Physical Assessment*

Rows	Almost Never	About Half of the Time	Almost Always
Successfully manipulates objects with hands
Walks independently
Runs independently
Has enough energy for daily activities
Can endure 30 minutes or more of physical activity
Sees objects close up clearly
Sees objects far away clearly
Hears most noises
Feels touch. pressure, etc.

Activities of Daily Living*

Rows	Almost Never	About Half of the Time	Almost Always
Toilets self
Feeds self
Dresses self
Takes care of personal hygiene

If your child requires specific assistance with any of the above Activities of Daily Living, please describe how they need to be assisted.*

Behavior Assessment*

Rows	Never	Rarely	Sometimes	Often
Strikes Others
Bites Others
Scratches Others
Uses Foul Language
Strikes Self
Bites Self
Scratches Self
Purposefully Runs Away
Wanders Off

Goals 1-least important, 4-most important*

Rows	1	2	3	4
Increase leisure; willingness to participate in recreational activities
Increase social skills; taking turns, sportsmanship, rule following, making needs known, etc.
Increase physical skills; endurance, coordination, etc.
Increase cognitive skills; learning rules, attention, learning flow of game, etc.

Please describe camper's likes:*
Please describe camper's dislikes:*
Describe what triggers anxiety and/or escalating behavior:*
What are calming or deescalating activities that work best for the camper:*
Please describe anything else you think would help us with the camper:*

Childcare Behavior Policy
All parents/guardians must sign for- Behavior Policy:*
Parental/ Participant Statement of Agreement Assumption of Risk, Liability Release, Indemnification and Refund Policy
1. Assumption of Risk: I hereby acknowledge and agree that my child’s participation in recreational activities involves inherent foreseeable and unforeseeable risks and hazards which may expose my child, or me, to illness, injury, or death. In consideration of my child’s participation in such activities, I for myself, my child, my heirs, my executors and administrators, freely and voluntarily agree to assume and accept any and all risks to my child or myself associated with my child’s participation in Salt Lake County recreational activities.2. Release: In consideration of my child’s participation in the Salt Lake County recreational activities, I, for myself, my child, my heirs, my executors and administrators hereby release Salt Lake County and its officers, agents, and employees from any cause of action, claim, or demand of any nature whatsoever I or my child may now have, or have in the future, against Salt Lake County on account of personal injury, property damage, death, or accident of any kind, caused by, arising out of, or in any way related to my child’s participation in Salt Lake County recreational activities. 3. Indemnification: In consideration of my child’s participation in the Salt Lake County recreational activities, I agree to indemnify and hold harmless County, its officers, agents, and employees from any and all causes of action, claims, demands, losses, or costs of any nature whatever cause by, arising out of, or in any way related to my child’s participation in the Salt Lake County recreational activities. I agree that my duty to defend and indemnify the County under this Agreement includes all attorney fees, litigation and court costs, expert witness fees, and any sums expended by or assessed against the County for the defense of any claim or to satisfy any settlement, arbitration award, or verdict paid or incurred on behalf of the County arising out of or in any way related to my child’s participation in the Salt Lake County recreational activities.4. Refund: Refunds may only be requested in person and must be accompanied by a written request. As per Salt Lake County policy and procedures the Parks and Recreation Division may withhold 25% of the refund (program registration fee) for administrative costs. No refunds shall be given after the first day of the program.5. Collections: I agree to pay Salt Lake County all costs incurred, together with reasonable attorney’s fees in the event that my account is referred for collection. I understand that any account delinquent 30 days or more will be turned over to collection.6. Emergency Treatment: I hereby authorize Salt Lake Parks and Recreation program staff to act on my behalf in accordance with their best judgment in case of an emergency involving my child, and agree to assume full responsibility for all expenses, medical or otherwise, that may arise therefrom. 7. Media Consent: I hereby grant permission to Salt Lake County to use my or my children’s photograph, videotaped image, quotes/comments, or name for publicity and educational purposes in any and all publications and media without limit or compensation.8. Name Posting: Unless otherwise indicated below, Salt Lake County is authorized to post or publish the name of my child participating in Salt Lake County recreational activities on the Salt Lake County website.
By signing this assumption of risk, liability release, and refund policy statement, I acknowledge that I have read its contents and disclosure, that I understand its contents and disclosure, and that I agree to its terms. If any portion of this Agreement is held to be invalid by a court of law, then it is agreed and intended that all the remainder shall, notwithstanding, continue in full force and effect.*
I consent to my child's participation in Salt Lake County Parks and Recreation sponsored activities, including swimming and field trips and transportation in County operated vehicles to those activities. In addition, I give Salt Lake County staff permission to sign my child in and out when transporting to and from the recreation center.*
In case of an emergency or a serious illness and the parents cannot be reached immediately, I herby authorize Salt Lake County Parks & Recreation to obtain emergency medical care and/or provide emergency medical transportation for my child.*

Please upload a recent picture of your child, if possible, so our staff may get to know them better. If you cannot upload it, please email it to rmbrown@saltlakecounty.gov:

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2026 Adaptive Summer Camp Application Form