MALAYSIA DAY CAMP 2018 CAMPER FORM [by application only]
Date: 15th - 17th September 2018
Venue: Methodist College Kuala Lumpur (MCKL)
Full name of young person *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Name of Parent / Caregiver / Guardian *
Your answer
Handphone no. of Parent / Caregiver / Guardian *
Your answer
Email address of Parent / Caregiver / Guardian *
Your answer
What is the young person's t-shirt size? *
Primary Disability *
Your answer
Onset of Disability
Your answer
Extent of Disability
Your answer
Cognitive Functioning Level *
If below age, what is the young person's functioning age?
Your answer
If intellectual disability is involved, the young person is classified as: *
The young person is oriented to: *
Required
COMMUNICATION AND MOBILITY
Communication: Is the young person fully independent? *
Does the young person: *
Yes
No
Speak clearly
Use communication device
Use Braille
Use hands more than speech
Use facial expression to respond
Use modified sign language
Require large print materials
Additional Information
Your answer
Mobility: Is the young person fully independent? *
Does the young person: *
Yes
No
Ambulatory (able to walk)
Use manual wheelchair
Use electric wheelchair
If ambulatory, the young person walks: *
Yes
No
Unaided
Need assistance with steps and slopes
If wheelchair does he/she : *
Yes
No
Push self
Need assistance
What is the young person's height: *
Your answer
What is the young person's weight: *
Your answer
PERSONAL CARE INFORMATION
Is the young person incontinent? *
Has the young person been away from home before? *
Supervision: Is the young person fully independent? *
Does the young person need: *
Yes
No
Close supervision [one- to- one]
General supervision
The young person needs supervision, for which activities?
Your answer
Feeding: Is the young person fully independent? *
Does the young person: *
Yes
No
Feed self
Use fork
Use spoon
Requires cutting assistance
Does the young person need to be fed: *
Yes
No
With fork
With spoon
Does the young person: *
Yes
No
Need straw
Need bib
Have special utensils or dishes
Additional Information :
Your answer
Toileting: Is the young person fully independent? *
Assistance needed: *
Yes
No
At all times
Close supervision
General supervision
Please specify if assistance is needed
Your answer
Participants Fee
RM 890
Additional Information:
Your answer
PARTICIPATION
Any limitations to participation in activities?
Your answer
How will you measure the success of the young person's participation at this boot camp? *
Your answer
MEDICAL NEEDS
Summarise the young person's medical needs [be specific]:
Your answer
Food allergies: *
Your answer
Special dietary requirements: *
Your answer
Does the young person experience SEIZURES : *
If yes, what is the type, duration, frequency and date of last seizure?
Your answer
Any additional information that will be helpful if the young person experience a seizure?
Your answer
BEHAVIOURAL INFORMATION
Is the young person aggressive towards themselves or others? *
If yes, when was the last occurrence?
Your answer
Please describe any behaviours we should be prepared for and how to resolve them:
Your answer
Failure to disclose information will result in the young person being sent home and loss of fees. Please provide Oasis Place as much information as possible in order for us to properly care for the young person. Physical aggression, sexual aggression and verbal aggression towards others cannot be tolerated.
Name of person submitting this online form *
Your answer
Relationship to the young person *
Your answer
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