1. CHILD'S SECTION

ABOUT CHILD

Question Title

* 1. What is your first name?

Question Title

* 2. What is your last name?

Question Title

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

Question Title

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

Question Title

* 5. What is your child's birthdate?

Date / Time

Question Title

* 6. What is your child's age?

Question Title

* 7. What is your child's gender?

Question Title

* 8. Current grade in school?

Question Title

* 9. The number of brothers and sisters?

Question Title

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

Question Title

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

Question Title

* 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?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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

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

Question Title

* 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?

Question Title

* 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?

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?

Question Title

* 33. Does your child have any allergies?

Question Title

* 34. Does your child have any major dietary restrictions?

Question Title

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

Question Title

* 36. Is your child currently taking any medications?

Question Title

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

0 of 59 answered
 

T