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Camp Communicate Application
Parent/Caregiver Information
First Name
Your answer
Last Name
Your answer
Full Mailing Address
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Phone Number
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Email
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Camper Information
First Name
Your answer
Last Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Grade (2016-2017)
Medical Diagnosis
Your answer
Food Sensitivities/Allergies (Please List)
Your answer
Current Therapy (Please indicate Speech, OT, PT, ABA and minutes attending per week)
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My Child uses AAC
If yes, what type of device(s) and software?
Your answer
My child is able to work cooperatively for 3 hours
My child recognizes ___/26 letters of the alphabet
Your answer
My child has sound-letter awareness for
My child
Assign Value to all that apply
Childhood apraxia of speech
Dysarthria
Articulation/phonological disorder
Expressive language delay
Receptive language delay
Autism Spectrum Disorder
Challenging Behaviors
Intellectual Developmental Disorder
Hearing Loss
Other (Please list/describe)
Your answer
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