Camp Behavior Works Registration

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Camp Behavior Works Registration

Camper Information

Full Name

Date of Birth

YYYY

Age

Medical History

Does your child have any current or past medical conditions? (YES/NO- If yes, please indicate)

Is your child currently taking any medications? (YES/NO- If yes, please indicate)

Has your child ever been hospitalized or had surgery? (YES/NO- If yes, please indicate)

Does your child use any of the following?

Glasses

Hearing aids

Medical devices (e.g., insulin pump)

None of the above

Allergy Information

Does your child have any allergies? (YES/NO- If yes, please indicate) *

Does your child have a peanut allergy?

Yes

Clear selection

Allergy severity

Mild

Moderate

Severe (Anaphylaxis)

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Does your child require an EpiPen? *

Yes

Behavior Profile

Has your child been diagnosed with any of the following? (Check all that apply)

Autism Spectrum Disorder (ASD)

ADHD/ADD

Sensory Processing Disorder

Down Syndrome

Anxiety Disorder

Oppositional Defiant Disorder (ODD)

Speech/Language Delay

Other:

Please describe your child’s current level of communication

Verbal – speaks in full sentences

Verbal – uses single words or short phrases

Nonverbal – uses AAC device

Nonverbal – uses gestures or signs

Other:

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Does your child exhibit any of the following behaviors we should be aware of?

Elopement (running away)

Physical aggression

Self-injurious behavior

Property destruction

Pica (eating non-food items)

Tantrums/Meltdowns

Sensory-seeking behaviors

Other:

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