1. CHILD'S SECTION

ABOUT CHILD

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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?

Date / Time

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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?

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

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

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* 15. Is your child available for the full two weeks? (Sunday June 16-Friday June 28th)?

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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?

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

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

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

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

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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.

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* 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.

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* 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 Summer Camp?

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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)?

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

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* 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 any major dietary restrictions?

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

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* 36. Is your child currently taking any medications?

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* 37. Will a nurse need to administer medication to your child during program hours?

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