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Childcare Application - Spring Community Workshop
Please tell us about your child. If you wish to apply for multiple children, there will be an option to complete a form for each additional child. Don't forget to RSVP for the Spring Community Workshop at ATXABA.COM. See you February 19th!
Caregiver Name *
Your answer
Caregiver Email
Your answer
Caregiver Phone Number *
Your answer
Child's Full Name *
Your answer
Child's Age *
Your answer
If your child receives therapy services, please list all therapy centers your child works with.
Spectrum Sitters, our childcare provider, must ensure that the sitters do not work at the therapy centers that your children attend. Please list your child's therapy centers so we can appropriately match sitters for the Community Workshop.
Your answer
Child's Diagnosis *
Your answer
My child mainly communicates by: *
Any other information about how your child communicates that would be helpful for us to know:
Your answer
Disruptive Behavior *
What challenging behaviors does your child use?
Does not occur
Is unlikely to occur
May occur in specific situations
Is likely to occur
Will definitely occur
Physical aggression - hitting, biting, kicking, pulling hair, or otherwise harming other people
Property destruction - throwing things, slamming doors, kicking walls, or otherwise harming property
Self-injury - head banging, biting self, hitting self, or otherwise harming oneself
Elopement - running away or leaving an area without permission
Tantrum behavior - crying, screaming, falling to the ground, stomping
Verbal aggression - making threats, using profanity
Additional information on disruptive or challenging behaviors we may see *
Your answer
What activities, environments, events are likely to make challenging behavior occur
Your answer
When challenging behavior occurs what is effective in helping your child to calm down or stop the behavior. *
Your answer
Reinforcers *
Please list all toys, games, activities, topics, characters, TV shows, songs, movies, books that your child loves.
Your answer
I need to add information for another child *
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