YMCA of Cape Breton Summer Day Camp 2019

Registration Package

This package contains all of the forms and information required to register your child for summer day camp at the YMCA of Cape Breton. Please bring the following with you on registration day: • Parent policy handbook read and signed • Registration form completed and signed • $50 Deposit • Void cheque (if applicable)

PLEASE NOTE: Forms will only be accepted in person at the Frank Rudderham YMCA on the registration dates noted below. Completing these forms in advance does not guarantee your child’s registration in day camp. Registration is filled in a first come, first serve basis. A child will only be confirmed at registration by a YMCA Staff Member.

REGISTRATION DATES

Special Support May 23, 2019 5:00 pm Registration by email Ryan.MacLean@cb.ymca.ca

Members and returning campers

May 27, 2019 4:00 – 7:00 pm Registration in person only

Non-Members and new campers

May 31, 2019 4:00 – 7:00 pm Registration in person only

If you have any questions or concerns, please contact Ryan MacLean, Children and Youth Coordinator at (902)569-9622 ext 2225 or Ryan.MacLean@cb.ymca.ca

YMCA of Cape Breton 2019 Summer Day Camp - Registration and Payment Form

Payment Agreement: • The week(s) your child will be attending day camp must be paid in full prior to attending • A non-refundable down payment of $50.00 is required at the time of registration to secure your child’s spot • Payment arrangements for the balance owing is required at the time of registration • Any child who is receiving a subsidy or third party billing must have those arrangements made prior to enrolling their child • No refunds will be issued. Refunds are not given for sick days or days unattended. • Requests to change dates will not be accepted as all registration dates are final. • Failure to pay balance of childcare will result in your account going to collections and restrict registration to YMCA programing.

Child’s Name:

Parent or Guardian: Week 1 2-Jul-19 5-Jul-19 $ 136.00 Week 2 8-Jul-19 12-Jul-19 $ 170.00 Week 3 15-Jul-19 19-Jul-19 $ 170.00 Week 4 22-Jul-19 26-Jul-19 $ 170.00 Week 5 29-Jul-19 2-Aug-19 $ 170.00 Week 6 5-Aug-19 9-Aug-19 $ 170.00 Week 7 12-Aug-19 16-Aug-19 $ 170.00 Week 8 19-Aug-19 23-Aug-19 $ 170.00 Week 9 26-Aug-19 30-Aug-19 $ 170.00 Total Cost: Less Payment: Balance Owing:

CHECK OFF PAYMENT DATES:

June 1 $ June 15 $ July 1 $ July 15 $

PAYMENT METHOD:

Bank Account Information (Please attach void cheque)

Credit Card Information Visa MasterCard Name on Card:

Card Number: _________/_________/_________/__________ Expiry Date: ______ /_______

OFFICE USE ONLY:

PREAUTHORIZED DETAILS AND PAYMENT AGREEMENT:

You, the Payer, authorize The YMCA of Cape Breton to charge your account or credit card listed above for the amounts and dates listed. I agree with the payment agreement above and the weeks selected for my child. I know that once these weeks are selected they cannot be changed and I am responsible for full payment, regardless of attendance. No refunds will be given.

Parent’s Signature Date

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YMCA of Cape Breton Children and Youth Department

Summer Day Camp

Parent Policies And Procedures

Building Healthy Communities

YMCA of Cape Breton

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Summer Day Camp Policies and Procedures

Established in 1886, the YMCA of Cape Breton is the oldest, most diverse charity on Cape Breton Island. The YMCA is a volunteer driven, charitable organization serving all areas of Cape Breton Island. We operate facilities in Sydney, Membertou, Glace Bay, Port Hawkesbury and New Waterford. Our Values The YMCA of Cape Breton is committed to practicing and demonstrating our core values of respect, honesty, responsibility, and caring in all aspects of the organization. Our Mission The YMCA of Cape Breton is dedicated to the growth of all persons in spirit, mind, and body and in a sense of responsibility to each other and the global community. We fulfill our charitable mission by meeting the needs of our community in seven key functional areas

• Employment • Re-Education and Training • Child Care • Entrepreneurship • Day Camp • Wellness and Preventative Health • International Development

YMCA Etiquette Statement The YMCA of Cape Breton is a shared experience for everyone. Each of us can make it better for all by being considerate of others. YMCA participants, volunteers and staff all pledge to treat one another with caring, honesty, respect and responsibility. YMCA of Cape Breton Children and Youth Department Mission Statement The mission of the YMCA of Cape Breton Children and Youth Department is to provide support to families and to promote the development of the whole child by providing carefully planned, age appropriate, stimulating and child-centered programming. Our goal is to promote the importance of:

• Social acceptance by developing an understanding of other’s needs and feelings. • Emotional health by developing a positive self-image and respect for individual differences. • Intellectual ability by developing each person’s enthusiasm for testing his/her own abilities. • Physical health by developing a positive attitude toward physical activity and hygiene

Philosophy Statement The YMCA of Cape Breton Children and Youth Department believes in a Family Centered Approach. We believe that each child is special and unique and deserves quality programs delivered in an environment that is safe, warm, loving, challenging, and stimulating. Our programs promote the growth and development of the whole child: physically, emotionally, socially and intellectually. We believe that our programs will ensure a child’s continued enthusiasm and capacity for life-long learning.

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At the YMCA of Cape Breton we believe that parents are an integral part of our program. Through partnerships with families and communities we are able to strengthen our ability to meet the needs of children and youth. Our job is to support parents by providing a safe environment for their child. Using a team approach, we can ensure that each young member has the maximum opportunity to grow and develop to his/her/their full potential. Inclusion Philosophy The YMCA of Cape Breton Children and Youth Department, in keeping with our mission and vision, believes in the development of healthy confident children. We’re committed to treating children with respect and dignity and helping them grow and develop to their full potential. We believe that each child is special and unique and deserves quality programs that are safe, warm, loving, challenging and stimulating. Our program is open to all children regardless of their abilities or disabilities. Central to our work at the YMCA is diversity and social inclusion. We believe that all children and families should have an inclusive and respectful experience in our programs. YMCA programs are designed to develop children in spirit, mind, and body. Every child is a unique individual and will add value to our program. Parents and families are involved, consulted and informed partners with YMCA staff and volunteers. YMCA staff and volunteers (where appropriate) will strive to ensure the environment and programs are adapted to meet the needs of all children. YMCA staff and volunteers (where appropriate) will seek out community partners to enhance our ability to support children with special needs through training and consultation. Summer Day Camp Activities During your child’s day with us he/she/they will participate in a variety of activities that will allow them to develop their healthy mind, body, and spirit including:

• Weekly themes • Variety of activities including: art, drama, music, games • Small and large group activities • Supervised swimming • Gym activities • Field trips • Outdoor play

Registration Procedure –Summer Day Camp

• Spaces are filled on a first come, first served basis. • Children must be between the ages of 5 and 12 and must have completed their first year of

school. • Parents can book full weeks during the following registration times:

Special Support May 23, 2019 5:00 pm Registration by email Ryan.MacLean@cb.ymca.ca

Members and returning campers May 27, 2019 4:00 – 7:00 pm Registration in person only

Non-Members and new campers May 31, 2019 4:00 – 7:00 pm Registration in person only

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• Registration package completed including parent or guardian’s signature for outings, emergency medical attention, parent policy agreement, medical information is up to date, payment form.

• A $50.00 (non-refundable) registration fee has been paid (used toward day camp fees) • Custodial arrangements are on file where applicable • Children who require additional supports must have inclusion form filled out to help us provide

the best possible day camp experience Fee Structure

• Summer Day Camp - $170.00 per week $34.00 per day • The week(s) your child will be attending day camp must be paid in full prior to attending • A non-refundable down payment of $50.00 is required at the time of registration to secure your

child’s spot • Payment arrangements for the balance owing is required at the time of registration • Any child who is receiving a subsidy or third party billing must have those arrangements made

prior to enrolling their child • No refunds will be issued. Refunds are not given for sick days or days unattended. • Requests to change dates will not be accepted as all registration dates are final. • Failure to pay balance of childcare will result in your account going to collections and restrict

registration to YMCA programming. • Child Care Income Tax Receipts will be available for pick up at the front desk in February 2020.

You will receive notification via email when they are ready for pick up. Hours of Operation The Summer Day Camp runs Monday to Friday from 7:30 a.m. to 5:30 p.m. from July 2nd– August 30th,

2019 and will be held at the Frank Rudderham family YMCA (399 Charlotte Street, Sydney, NS B1P 1E3) Sick Days A child must be well enough to participate fully in the summer camp daily program, including swimming, out door and gym play. Parents are asked to call the YMCA if their child will not be attending due to illness. Full Fee will apply to all sick days Attendance To ensure the constant safety of your children, all parents must accompany their children to the designated camp room upon arrival. Parents are not to leave children alone in foyers, hallways or classrooms. Please inform anyone involved in transporting your child of these procedures. We ask that each child greets the camp staff upon arrival and says goodbye when leaving. Please sign your child in and out of day camp daily. The attendance book also allows our staff to know who is in the building at all times which is especially important during emergency procedures and evacuations. Health and Wellness The promotion of healthy development is fundamental to YMCA programs. We know this is important to parents of young children, therefore, please do not bring a sick child to any of our programs. A parent or emergency contact will be called to pick the child up should a child become unwell or develop symptoms. We ask that your child be kept at home until all symptoms of the sickness disappear. We

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may ask for a doctor’s note before re-admitting a child to our program. Children must be well enough to participate in all of our daily routine. It is necessary that parents develop a back- up plan for the care of their child in the event of illness. This plan should be communicated with the Centre. Late Departure Fee If you or the person designated to pick up your children are going to be late, please notify the YMCA immediately. Parents who pick up their child after 5:30 pm will be charged $10 for every 5 minutes. We ask that parents adhere to our hours of operation and recognize that our staff also have family commitments. Parents who are consistently late may have their space terminated. Withdrawal of Service The YMCA of Cape Breton may withdraw services in the following situations:

• Non-payment of program fees • Chronic late pick-up • Situations that require specialized services that the YMCA is not able to provide • Parents or children who exhibit abusive behaviour towards staff, volunteers, other children and

families • Children who are unable to manage in group settings • Refusal by parent/guardian to meet with the YMCA staff and/or consent to the use of support

services for children Financial Help You or someone you know may qualify for financial support and can apply for the YMCA Opportunity Fund. As a registered charity, the YMCA of Cape Breton is committed to serving the community through building strong kids and strong families. Applications for opportunity Fund are available upon request. Insufficient Funds A supplementary fee of $20 will be charged to your account for any payment returned to us from the bank (i.e. NSF). After an NSF charge has occurred it is the parent’s responsibility to provide the YMCA with cash or certified cheque to cover the account balance that was returned NSF plus the NSF $20.00 fee. Medication From the NS Day Care Act and Regulations Selected Day camp staff is authorized to dispense medication only after the necessary forms are completed and signed by the parents. Prescription Drugs - may be administered as ordered by the physician, and as stated on the original (readable) prescription container for the child, once a YMCA Medication Permission Form has been filled in by the parent. Non-prescription Drugs – may only be administered by YMCA staff if the medicine is supplied in the original container and the parent fills in and signs the YMCA Medication Permission Form to be kept on file. Parents must send dispenser/measuring utensils along with any medication.

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Medication of any kind is not to be left in a child’s backpack! All medication should be given to the camp staff. All medication and medical supplies must be properly stored in a locked cupboard or locked box in refrigerator. Allergies/Food Sensitivities Children who attend our Day Camp are required to bring their own lunch and snacks daily. Children are also required to bring a water bottle as well. We are a peanut-sensitive facility. We ask that you please take into consideration food sensitivities/allergies when doing so. Please inform the Centre of any food allergies or diet restrictions your child may have. Emergencies In the case of a serious accidental injury or illness, we will make an immediate call for an ambulance, and then attempt to contact: (in order) 1. The parent(s) 2. The designated emergency contact person/back up care in event of illness 3. The child’s physician In the event of an early closure due to an emergency, the staff will do everything possible to contact the parent or emergency contacts. Notifications will also be posted on our website, facebook page and the local radio stations. Please ensure that we have current phone numbers, address changes, special emergency numbers and contact persons, custodial arrangements, schedules, and any other pertinent information on file. All parents or guardians must sign an Emergency Medical Attention Form Privacy At the YMCA of Cape Breton, we respect your privacy. We protect your personal information and adhere to all legislative requirements with respect to protecting privacy. We do not rent, sell or trade our mailing lists. The information you provide will be used to deliver services and to keep you informed and up-to-date on the activities of the YMCA of Cape Breton, including programs, services, special events, funding needs, opportunities to volunteer or to give, open houses and more through periodic contacts. If at any time you wish to be removed from any of these contacts simply contact us by phone at 1-902-562-9622 and we will gladly accommodate your request. Media The YMCA receives occasional requests from the media for photographic, audio or videotape material of YMCA of Cape Breton Children and Youth Department programs and activities. When agreeing to these requests, the YMCA will attempt to notify parents, and obtain permission for specific media events, but because of the time factor, this is not always possible. We ask that you be aware that this may occur, and that you discuss with the director of children and youth any concerns you may have regarding your child/family and the media. What You Will Need To Bring Children should wear inexpensive, comfortable clothing so that they can participate in all aspects of the program. Please ensure that children have:

• Sneakers

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• Lunch • Hat • Bathing suit and towel • Sunscreen • Water/beverage bottle • Change of clothes

Behaviour Management Policy The staff of the YMCA of Cape Breton Children and Youth Department will follow the guidelines outlined in the Behaviour Guidance Policy from the Nova Scotia Department of Community Services. The following policies are designed to help a child develop self-control and self-confidence so that she/he/they will have the ability to act appropriately in given situations. We recognize that a well-planned program with a variety of interesting and developmentally appropriate activities helps to prevent many inappropriate behaviours. Through our program our staff will help the children in our care develop and grow by using play as a way to teach appropriate behaviours. The following Behaviour Management Techniques will be used by the staff of the YMCA of Cape Breton Children and Youth Department:

• Redirection - whenever possible staff will use redirection as the primary tool in behaviour guidance. Many inappropriate behaviours can be curbed when the staff are observant and direct the child to a different activity

• Acceptable Alternatives - the staff will explain why a behaviour is unacceptable and provide an alternative behaviour, ie. “When you throw sand at Johnny, it hurts his eyes. Please keep the sand in the sand box”. It is done in a matter of fact way and in terms simple enough for a child to understand.

• Positive Reinforcement - The teacher will recognize when a child is displaying appropriate behaviour and reward the behaviour with praise, ie. “Kelly you helped Suzy put the blocks away, good helping”.

• Positive Directions - when speaking with the children staff will use positive phrasing rather than the negative, ie. “walk please’ instead of “don’t run inside”.

• Offer Choices - the staff will offer the children acceptable alternatives, ie. “Do you want to clean up the playdough or the puzzles?” instead of “Do you want to clean up?” which will invite a “No” response from the child.

• Positive Role Modelling - The staff will model appropriate behaviours for the children each day in all aspects of their day.

• Setting Limits - The staff will set age appropriate limits in a positive way with occasional reminders when needed.

• Time Out - When a child is hurtful or aggressive the teacher may remove a child from the situation in order for the child to calm down and ensure the safety of everyone. Such “Time Out Talks” are brief and to the point, perhaps a minute away from the action. The teacher will explain why such behaviour is inappropriate and unacceptable and in terms the child can understand. The behaviour and not the child is bad. When Time Out is used the teacher will inform the parent of the situation.

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Good Behaviour Management - NEVER ridicules, insults or scares, BUT instead guides, respects and reinforces positive behaviour. Staff Will Not:

• Use corporal or physical punishment in any form. • Use harsh, humiliating, belittling or degrading responses of any form, including verbal,

emotional or physical. • Confine or isolate children. • Deprive a child of the basic needs, including food, shelter, clothing or bedding (ie. with holding

meals, snacks or desserts) • Require or force a child to repeat physical movements.

Staff The YMCA of Cape Breton Children and Youth Department provides quality programs by employing qualified staff and volunteers who fulfill our high expectations for program delivery. Day Camp staff are supported and guided by the Coordinator of Children and Youth and together we work as a team to ensure that the standards and services are consistent and appropriate. All YMCA of Cape Breton Children and Youth Department staff receives a full week of training and orientation in regards to our programs, policies, and procedures prior to working with the children. All of our staff must have a valid First Aid and CPR Training Certificate and are screened through the Child Abuse Registry and have had Criminal Record Checks completed. Under the Influence Children will not be released from our program to accompany a parent or guardian who appears to be under the influence of drugs or alcohol. In such circumstances, our staff will call the other parent/guardian, or emergency contact person, and request that he/she come to pick up the child. The police will be contacted if the child is taken from the premises despite staff concerns. Duty to ReportIf our staff suspects that a child is being abused or neglected they will contact the local child welfare agency. Everyone has the duty to immediately report to a child welfare agency even a suspicion that a child under 16 may be in need of protective services. Once a report is made, child protection staff considers the information provided to determine whether an investigation into the matter is necessary. Parent Involvement The YMCA of Cape Breton Children and Youth Department believes that parent-staff communication is important for the creation of a healthy child environment. Please make an effort to stay up to date with our program information, and be sure to communicate to us any relevant information regarding your child’s experiences outside of our program. If at any time you wish to discuss a matter with one of our staff or our coordinator please do not hesitate to contact us.

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I acknowledge that I have read and understood the above policies and procedures in its entirety and agree to abide by them.

Parent’s Signature Date

YMCA of Cape Breton

Summer Day Camp 2019 Registration Form

Child’s Name: ____________________________________________________________________________ Nickname: ______________________________________________________________________________ Date of Birth: ____________________________________________________________________________ What grade is your child entering in September? _______________________________________________ What school does your child attend? _________________________________________________________ Home Address: Mailing Address: ____________________________________ ______ _______________________________________ ____________________________________ ______ _______________________________________ __________________________________________ _______________________________________ Home Phone Number: _____________________________________________________________________ Parent/Guardian (1): ___________________________ Home Phone: ____________________________ Employer: ____________________________________ Work Phone: ____________________________ Cell Phone: ___________________________________ Email: __________________________________ Parent/Guardian (2): ___________________________ Home Phone: ____________________________ Employer: ____________________________________ Work Phone: ____________________________ Cell Phone: ___________________________________ Email: __________________________________

Emergency Contact Number (if parent/guardian cannot be reached) Name: _______________________________________ Phone: ___________________________________ Name: _______________________________________ Phone: ___________________________________ Who other than the child’s parent/guardian has permission to pick the child up from the program? Name: ___________________________________ Relationship: _______________________________

Name: ___________________________________ Relationship: _______________________________ Background Information Language(s) spoken at home: __________________________________________________________________ Has your child had any experience with Day Camp or structured child care before? Yes _____ No _____ Please describe the child’s experience: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has your child been cared for by other family members or neighbours? Yes _____ No _____ Please describe the child’s experience: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is this your child’s first experience in the YMCA Summer Camp? Yes _____ No _____ What is your child’s comfort level in regards to the pool? _________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ Other than school, has your child had any other structured group experience? (ie. Brownies, Cubs, sports) Yes _________ No __________

Please describe the child’s experience: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Health and Development History Describe your child’s general health: (ie. recurrent colds, ear infections, stomach aches, etc.) __________________________________________________________________________________________ __________________________________________________________________________________________ Are there currently any serious medical problems? Yes _________ No ________ __________________________________________________________________________________________ __________________________________________________________________________________________ If your child is taking any medications, what is the medication and what is it for: (if the child requires medication to be administered during the program a Medical Administration Form must be filled out prior) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child have any allergies: (food, medications, environmental) Yes _____ No _____ If yes please list along with the symptoms: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is the allergy severe enough to require medication or emergency treatment? Yes _____ No _____

If yes please describe in detail any medications or treatment required: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child have any diet restrictions: (cultural, religious) Yes _______ No _______ __________________________________________________________________________________________ __________________________________________________________________________________________ Name of Family Doctor: Phone Number: _________________________________________ ____________________________________ Address: __________________________________________________________________________________ __________________________________________________________________________________________ Behaviour Patterns and Habits Describe your child’s behaviour and habits: (ie. temperament, energy level) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Describe how your child communicates: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ How would you describe your child’s emotional, physical, social growth and development to this point?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Describe your child’s particular attachments: (ie. toy, blanket, pet, person) and any particular habits (ie. thumb sucking, rocking) __________________________________________________________________________________________ __________________________________________________________________________________________ Describe any particular fears your child has shown: (ie. to animals, loud noises, strangers) __________________________________________________________________________________________ __________________________________________________________________________________________ Describe how your child reacts to stressful situations: (ie. cries, withdrawals, temper tantrum, nightmares) __________________________________________________________________________________________ __________________________________________________________________________________________ How does your child usually react to new situations? __________________________________________________________________________________________ __________________________________________________________________________________________ We would appreciate your views on guiding your child’s behaviour and setting limits: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is there anything else that you feel we should know about your child that will assist us in providing them with a positive camp experience?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Parent Policy and Procedures Agreement I have read the policies and procedures for the YMCA of Cape Breton Multi Activity Camp. This includes the behaviour guidance policy, fee structure, health, and attendance policies. I understand my responsibilities as a parent / guardian and agree to abide by these policies and procedures. __________________________________________ __________________________________________ Parent/Guardian Signature: Date: Outside Expeditions I am willing for my child ________________________________________________ to go on outside expeditions with adequate adult supervision. _______________________________________ __________________________________________ Parent/Guardian Signature Date Emergency Medical Attention I am willing for my child ________________________________________________to have medical attention and be taken to the hospital in the case of an emergency if I/we cannot be reached. ______________________________________ __________________________________________ Parent/Guardian Signature Date

YMCA of Cape Breton Summer Day Camp

Please fill out ONLY if your child requires special Support

Inclusion Policy The YMCA of Cape Breton Children and Youth Department believes that each child is special and unique and deserves a quality program that is safe, warm, loving, challenging and stimulating. Our program is open to all children regardless of their abilities or disabilities. Through our partnerships with families, government and community agencies we are able to strengthen our ability to meet the needs of all the children we work with. With limited funding for additional staff, this summer we are offering our campers who require additional supports one week time slots. Each family can choose one week for their child to attend so that we can serve as many families as possible. If there are any spaces left after each family has chosen a week, families will be able to pick further days for their child to attend. First choice time slots will be filled based on order of received applications. We will do our best to accommodate each family’s preference. Please indicate your preferred time slots for your child to attend (in order of preference) __________________________________________ ______________________________________ __________________________________________ ______________________________________ __________________________________________ ______________________________________ Are you interested in additional weeks if they are available? Yes____________ No____________ In order for us to provide the best possible day camp experience for your child, we ask that you give us as much detail as possible in regards to any additional supports your child may require. Does your child have a specific diagnosis? Yes____________ No___________ ______________________________________________________________________________________ ______________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Which professional gave your child the diagnosis? ___________________________________________ ______________________________________________________________________________________ Please list all the professionals and supports who work with your child

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child have any allergies (food, medications, environmental) Yes__________ No__________ If yes please list along with the symptoms: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is the allergy severe enough to require medication or emergency treatment? Yes________ No________ If yes please describe in detail any medications or treatment required: __________________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Does your child use any assistive devices (ie. wheelchair, iPod, picture board, etc)? Yes _______ No ______ If yes please describe: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ If your child is taking any medications, what is the medication and what is it for: (if the child requires medication to be administered during the program a Medical Admin Form must be filled out prior) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List the activities your child enjoys: _____________________________________________________________

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List any activities your child dislikes: ____________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ What are your child’s strengths? _______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ COMMUNICATION What current communication skills does your child have (for example, verbal, vocalizations, words, sign language, PECS, etc.) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is your child able to communicate their needs effectively? Yes _________ No _________ Is your child familiar with the use of visuals? Yes _________ No _________ If yes how and when are they used? _________________________________________________________________________________________ __________________________________________________________________________________________ SELF CARE

Does your child go to the washroom independently? Yes ________ No _________ If not please describe assistance required __________________________________________________________________________________________ __________________________________________________________________________________________ Is your child able to get dressed independently? Yes ________ No __________ If not please describe assistance required __________________________________________________________________________________________ __________________________________________________________________________________________ SENSORY Is your child hypo (under) of hyper (over) sensitive to any of the below. Please provide examples and strategies used to assist in regulating sensitivity. Tactile (touch, getting messy) _________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Auditory (sound, crowds) _____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Smell (certain scents ) ______________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Movement (swing, spin) ____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Visual (lighting, stimming) ____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Is your child aware of his/her sensitivities? How does he/she self-regulate? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ BEHAVIOUR Does your child have any behaviour issues (flight risk, aggressive, non-compliant, self injurious, self stimulatory etc.)? Please explain and describe __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ How often do the behaviours occur? What is their duration? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ What are the triggers / antecedents to the challenging behaviours? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ What are the usual interventions that you find effective? (ie. removed from situation) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ What are the most useful strategies in calming / de-escalation your child if they do become upset (ie. deep pressure, music, breathing techniques, remove from the environment)?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List any motivators or special interests your child may have __________________________________________________________________________________________ __________________________________________________________________________________________ How does your child do with transitioning between activities? __________________________________________________________________________________________ __________________________________________________________________________________________ How does your child do with changes to routine? __________________________________________________________________________________________ __________________________________________________________________________________________ Is there any other information you would to share with us to ensure your child has a successful day camp experience? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________ _____________________________ Parent/Guardian Signature Date

Thank you for taking the time to provide us with this information