RUMERTIME Summer Family Camp 2021 : A Social Emotional Wellness Program- Family Application Survey

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* 5. What is your child's birthdate?

Date / Time

Date

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* 6. What is your child's age?

8 years old

9 years old

10 years old

11 years old

12 years old

13 years old

14 years old

15 years old

16 years old

17 years old

18 years old

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* 7. What is your child's gender?

Female

Male

Other

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* 8. Current grade in school?

3rd grade

4th grade

5th grade

6th grade

7th grade

8th grade

9th grade

10th grade

11th grade

12th grade

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* 9. The number of brothers and sisters?

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* 10. Where is this child in the sibling order? example, "first child,? etc.

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* 11. Please list your child's current school?

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* 12. What are your child's strengths, special abilities, talents, interests?

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* 13. Please describe your child's challenges in structured settings such as the classroom, organized sports or after-school activities?

Very easy

Easy

Neither easy nor difficult

Difficult

Very difficult

Other (please specify)

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* 14. Please describe your child's relationships with peers?

Does he/she have a best friend?

Is it hard for him/her to make friends?

Is he/she a loner, etc. ?

Is he/she shy, withdrawn, etc. ?

Other (please specify)

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* 15. Is your child available for the full two weeks? (Sunday, July 11-Sunday July 25th)?

Yes

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* 16. Does your child receive any special services in school currently? If so, please provide details.

Yes

Other (please specify)

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* 17. Does your child spend time with a professional counselor?

A great deal

A lot

A moderate amount

A little

None at all

Other (please specify)

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* 18. Does your child spend time with a social worker?

A great deal

A lot

A moderate amount

A little

None at all

Other (please specify)

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* 19. Does your child currently have an Individualized Education Plan(IEP)?

Yes

Other (please specify)

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* 20. Does your child currently have a 504 Accommodations plan in school?

Yes

Other (please specify)

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* 21. What activities does your child currently participate in outside of school?

Sports

Dance

Volunteering

Other (please specify)

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* 22. What are typical triggers that get your child out of balance?

Being told "No"

Parental discord

School related issues

Other (please specify)

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* 23. Describe how your child interacts with other children outside of school?

Very positive

Positive

Neutral

Negative

Very negative

Other (please specify)

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* 24. What strategies calm your child down when he/she is upset?

Music

Time out

Outdoor activities

Other (please specify)

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* 25. Has your child engaged in any aggressive or unsafe behaviors, running away, inappropriate internet activity, or destruction of property in the past six months? If so please explain.

Other (please specify)

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* 26. Are you aware if your child is currently involved in any traumatic experiences?

Extremely aware

Very aware

Somewhat aware

Not so aware

Not at all aware

Other (please specify)

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* 27. Which of the following has been a challenge for your child? Choose as many as applies.

Poor Self-Image

Virtual Instruction

Negative Self-Concept

Suicide thoughts

inferiority complex brought on by social media

Anxiety

Unexplained school failure

Middle school transition issues

Negative thinking

Low self-esteem

School age related issues

Lack of motivation

Hopelessness

Self harm issues, e.g. cutting

Power struggle with parents

Depression

Makes bad choices

Can't make and keep friends

Emotional Outbursts, ex. anger outburst, cries a lot, moody

Poor self-control

Is a bully

Is bullied

Other (please specify)

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* 28. Has your child ever had a diagnostic/psychiatric evaluation?

Yes

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* 29. Is there anything else you would like to share that would help us better understand your child and his/her needs for the RUMERTIME Family Summer Camp?

Yes

Other (please specify)

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* 30. Please describe your child's treatment history(what type of provider; how often were appointments, the reason for treatment, was it helpful)?

Extremely effective

Very effective

Somewhat effective

Not so effective

Not at all effective

Other (please specify)

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* 31. Has your child ever been hospitalized for any psychiatric or medical reason? If so, please explain.

Yes

Other (please specify)

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* 32. Does your child currently have any serious medical or physical problems?

Yes

Other (please specify)

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* 33. Does your child have any allergies?

Yes

Other (please specify)

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* 34. Does your child have access to a digital device with internet access?

Yes

Other (please specify)

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* 35. Does your child have any physical limitations that would prevent him/her from participating in a typical RUMERTIME Family Summer Camp activity?

Yes

Other (please specify)

RUMERTIME Summer Family Camp 2021 : A Social Emotional Wellness Program- Family Application

1. CHILD'S SECTION

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your child's first name?

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* 4. What is your child's last name?

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* 5. What is your child's birthdate?

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* 6. What is your child's age?

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* 7. What is your child's gender?

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* 8. Current grade in school?

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* 9. The number of brothers and sisters?

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* 10. Where is this child in the sibling order? example, "first child,? etc.

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* 11. Please list your child's current school?

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* 12. What are your child's strengths, special abilities, talents, interests?

Question Title

* 13. Please describe your child's challenges in structured settings such as the classroom, organized sports or after-school activities?

Question Title

* 14. Please describe your child's relationships with peers?

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* 15. Is your child available for the full two weeks? (Sunday, July 11-Sunday July 25th)?

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* 16. Does your child receive any special services in school currently? If so, please provide details.

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* 17. Does your child spend time with a professional counselor?

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* 18. Does your child spend time with a social worker?

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* 19. Does your child currently have an Individualized Education Plan(IEP)?

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* 20. Does your child currently have a 504 Accommodations plan in school?

Question Title

* 21. What activities does your child currently participate in outside of school?

Question Title

* 22. What are typical triggers that get your child out of balance?

Question Title

* 23. Describe how your child interacts with other children outside of school?

Question Title

* 24. What strategies calm your child down when he/she is upset?

Question Title

* 25. Has your child engaged in any aggressive or unsafe behaviors, running away, inappropriate internet activity, or destruction of property in the past six months? If so please explain.

Question Title

* 26. Are you aware if your child is currently involved in any traumatic experiences?

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* 27. Which of the following has been a challenge for your child? Choose as many as applies.

Question Title

* 28. Has your child ever had a diagnostic/psychiatric evaluation?

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* 29. Is there anything else you would like to share that would help us better understand your child and his/her needs for the RUMERTIME Family Summer Camp?

Question Title

* 30. Please describe your child's treatment history(what type of provider; how often were appointments, the reason for treatment, was it helpful)?

Question Title

* 31. Has your child ever been hospitalized for any psychiatric or medical reason? If so, please explain.

Question Title

* 32. Does your child currently have any serious medical or physical problems?

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* 33. Does your child have any allergies?

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* 34. Does your child have access to a digital device with internet access?

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* 35. Does your child have any physical limitations that would prevent him/her from participating in a typical RUMERTIME Family Summer Camp activity?