Closing the Gap

Summer Camp Intake form

Child Information
Childs Name:
Birth Date:
Age:
Gender:
Home address:
City:
State:
Zip:
School:
Grade:
IEP: Yes
No
Date of last IEP:
Pertinent information summer camp staff should know from IEP:
Parent / Gaurdian name(s):
Phone(s):

E-mail:

In Case of Emergency
Emergency contact:
Phone:
Emergency contact:
Phone:

Relationship to child:
Relationship to child:

Individuals Authorized to Pick Up Child (other than parent/guardian)

Name:
Phone:
Name:
Phone:
Medical
History of seizures?
Yes
If yes, please explain:

No

Allergies?
Yes No
If yes, please explain:

Does he/she require an Epipen?

Asthma?

Does he/she use a preventative or rescue

inhaler? Yes No

Yes

No

If yes, please explain:

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Yes

No

Please list current services (PT, OT, Speech, etc.)

Please list any sensitivities / stressors (textures, lighting, sound,

physical contact, scent, etc.) that may create a feeling of panic for
the child. How are these sensitivities currently being addressed?

Does the child utilize an augmentative assistive communication

(AAC) system (sign language, picture exchange, voice output
device, iPad with AAC application)? If yes, please explain.

How does the child express his/her emotions?

Does the child need help using the restroom? If yes, please explain.

Does the child take any medications that would prevent him/her
from participating in any activities? If yes, please explain.

Does the child have any physical limitations? If yes, please explain.

Does the child have any additional medical conditions that the
summer camp staff should be aware of? If yes, please explain.

What techniques work best to transition the child from one activity
to the next?

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What techniques word best to calm him/her?

What are the childs biggest motivators?

Does the child seek or require sensory stimulation (physical pressure,

etc.)? If yes, please explain.

Is there a behaviour plan the summer camp staff should be aware

of? If yes, please explain or provide documentation?

Is there anything else you would like us to know about your child?

The information provided above has been completed to the best of my

knowledge.
Parent/Guardian Signature: __________________________________________
Date: __________________

Closing the Gap

summercamp@closingthegap.biz