2025 ASK Bilingual Summer Camp

GENERAL BACKGROUND
Mother tongue language (s)*
Other spoken/written language(s)
CLINICAL BACKGROUND
Diagnosis*
Other Diagnoses (if any)
Intellectual functioning *
Child’s communication level. Please list any communication aids/ supports your child uses. *
Childs’ strengths (please list any skills or special interests your child may have)*
Is your child toilet trained?*

YesNoOther
Child’s toileting routine, dressing routine and feeding routine (self-feed, etc.) *

CHILD INFORMATION
Child’s interests and likes:*
Child’s dislikes:*
Any sensory issues/triggers we should be aware of?*
Does your child have difficulty coping with any particular situations?*
Does your child ever engage in any behaviors of concern?*
Are there any triggers for these behaviors of concern that we should be aware of? *
What strategies work well with your child?*

MEDICAL INFORMATION
For the safety of the children and our team, we ask that you fill in this form as honestly and completely as possible. We guarantee the confidentiality of the information provided. We will use the information to provide the best nurturing environment for your child
Any know medical condition (s)*
Known learning differences diagnosis (if any): *
Medication(s) currently taking (if any): *
Known side effects of any medication(s) taken (if any):*
Please indicate if the child may suffer from seizures (frequency)*
Is there any other information which we should know? Kindly please describe/tell us in the space below:*
Known triggers to seizures:*

PERMISSION TO USE PHOTOS & IMAGES
ASK-All Special Kids may wish to use photographs and images from the programs undertaken as part of this collaboration. Any such images and photographs would highlight the participants either demonstrating learning techniques or participating in the ASK programs.

In accordance with ASK policy, the names of individual participants will not be released with photographs. This release form applies only to any educational publications and promotional materials published after 15 October 2012. I hereby authorise ASK to publish the photographs taken of me and/or the undersigned program participant, for use on ASK’s website and in any printed educational publications and/or general media releases.

I, {nameOf7}

release ASK from any expectation of confidentiality for the undersigned program participant and myself. I attest that I am the parent or legal guardian of the participant mentioned below and that I have the authority to authorise ASK to use their photographs and images. This release is valid from the date of signature until written notice is received from the parent/guardian revoking this Authorisation. I acknowledge that participation in publications and websites produced by ASK is voluntary, and neither the participant nor I will receive any financial compensation. I further agree that participation in any educational publications and website produced by ASK confers no rights of ownership whatsoever. I release ASK its owners, partners, volunteers, and employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned individual.
I agreeI do not agree
{nameOf}

{dateOf}

{nameOf7}
Date*

MonthDayYear
Date
Parent/ Guardian Signature:*

Clear
Child's Signature:

Clear

EMERGENCY CONTACT DETAILS
Please fill in the following tables with the contact details of two individuals whom we should contact in case of an emergency during the camp.
EMERGENCY CONTACT 1
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship to child:
Relationship to child:*
EMERGENCY CONTACT 2
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship to child:
Relationship to child:*

CHECKLIST
Please review the checklist before you send us your form:

Completed the contact information and emergency contact detailsCompleted the general questionnaire and child’s historyCompleted medical informationProvided us with your goals for your childSubmitted any previous reportsProvided a copy of your identity cardProvided a copy of your insurance detailsProvided a copy of travel card (we will be using public transport and it is useful for individuals to hold a valid TPG travel card)
Should be Empty:

ASK Bilingual Camp

CAMP DATES

GENERAL QUESTIONNAIRE

PERMISSION TO USE PHOTOS & IMAGES

CHECKLIST