ABA Spring Break Camp 2019
Email address *
Name of child *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Person Education Number (can be found on your child's IEP) *
Your answer
Parents Name *
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Phone Number *
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Address *
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City *
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Emergency Contact *
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Please check which weeks you would like your child to attend *
Required
Please indicate what size t-shirt your child will need *
Grade *
Your answer
Current School *
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What is your child's diagnosis(ses)? *
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Is your child currently on medication? *
Your answer
Does your child have allergies or sensitives? *
Your answer
Are there any other health or medical concerns?
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Does your child currently have a home-based program? *
Does your child currently have a behaviour consultant? *
If yes, who is the behaviour consultant?
Your answer
Does your child currently have a behaviour plan? *
Please email a copy of the behaviour plan to leahmumford@gmail.com
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