Embracing Abilities Teacher Consent Form
Note to Teacher: The following information is extremely important to help Embracing Abilities staff determine the best placement for the camper. Please be specific so that Embracing Abilities can provide the best experience possible for your student
Camper's Name
*
First Name
Last Name
Camper's School
*
Teacher's Name
*
First Name
Last Name
Teacher's Phone Number
*
Please enter a valid phone number.
Teacher's Email
*
Confirmation Email
example@example.com
Teacher Consent Form Questions
Please answer the questions below to the best of your ability
At what age level is the camper functioning?(Indicate months/years with age)
*
At what age level is the camper functioning within asocial context? (Indicate months/years with age)
*
Is the camper in a special education class? If so, what type?
*
Please describe camper receptive communication ability.
*
Please describe child’s expressive communication ability.
*
Please explain specific behavioral difficulties and successful management techniques, if any.
*
What level of personal care does camper receive at school (mobility, feeding, toileting, number of people required to assist, etc.)?
*
Does this camper exhibit aggression in the school setting?
*
Yes
No
If you answered yes to the previous question, please explain:
*
Does this camper have a 1:1 aide in the classroom?
*
Yes
No
If you answered yes to the previous question, what is the aide’s focus (e.g. academic support, physical assistance, behavioral support)?
*
To best support the camper in an accessible community/environment, what staff-to-child ratio would you suggest?
*
1:1
1:2
1:3
1:4
Please explain your selection for the previous question:
*
Please describe the campers strengths and academic goals:
*
Teacher Signature
*
Date Form Completed
*
Submit
Should be Empty: