Camp - Form - Registration

Summer Camp Registration

2019
The Tri-County Therapy summer camp program is a sensory and motor intensive therapy program designed for children with disabilities. The goal of each camp is to enhance overall development and motor skills to help children become more efficient and successful movers in a fun and safe environment. Each group in the program is assigned a certified therapist and dedicated volunteers.

Tell us about your child. (If any information is unknown please mark it as N/A)
Child's Full Name:*

First NameLast Name
Child's Nickname:
Child's Date of Birth

MonthDayYear
Date
MaleFemale
Phone Number:

Area CodePhone Number
Email Address:
example@example.com
Best form of contact:

PhoneTextEmail
Medical History

If any information is unknown, please type “NA” or “unknown”
Vision Problems

YesNo
If yes, please describe:
Hearing Problems:

YesNo
If yes, please describe:
Allergies:

YesNo
If yes, please describe:
Seizure Disorder:

YesNoOther
If yes, please describe:
Please list any other medical complications your child may have:
MEDICAL PRECAUTIONS: Are there any precautions the therapist should be aware of when working with your child?
Developmental/Educational History

If any information is unknown, please type “NA” or “unknown”
Has your child ever recieved Speech, Physical or Occupational Therapy? If so, when and where?
What are your child's current goals in therapy, if any:
What, if any, is your child's current medical diagnosis? (Autism, AHDH, etc)
How does your child play with other children? (Cooperative, leader, alone, aggressive, picked on, etc)
List any concerns you may have about your child's social skills:
Please check all that apply to your child's behavior:

Short Attention SpanSelf - Injurious BehaviorNo Specific ProblemsOther
What method of communication does your child use:

VerbalNon-VerbalCommunication DeviceSign Language

Please mark yes or no:

	Yes	No
Do others understand your child?
Does your child speak clearly?
Does your child stutter?

What are your primary communication concerns?

Can/Does Your Child... (Please mark yes or no):

	Yes	No
Throw and catch a ball?
Ride a trike/bike?
Use a pencil, crayon, or scissors?
Get dressed with little or no help from a parent?
Button, snap, zip, tie his/her shoes
Have sensitivity to textures/sounds?
Able to use a fork/spoon correctly?
Clumsy or bump into things often?
Need a routine/get upset if altered?
Have difficulty with transitions?

Please describe any mobility limitations your child may have:
What are your primary sensory or motor concerns?
Parent/Guardian Information
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Employer:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Relationship to child:
Does this child live with you?

YesNo
Do you have secondary parent/guardian information?

YesNo
Parent/Guardian Information
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Employer:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Relationship to child:
Does this child live with you?

YesNo
Pick Up Permission Form
For the safety and security of your child, we request a list of eligible “Pick-up People” who you authorize to pick up your child from the program each week.

For your child’s safety and security, only these individuals authorized by you as the parent/guardian will be allowed to pick up your child from Tri-County Therapy.

THIS FORM ONLY NEEDS TO BE COMPLETED IF THE PARENTS/GUARDIANS WHO COMPLETED THIS REGISTRATION PACKET MAY NOT BE PICKING UP THE CHILD. We will ask for identification from EVERYONE (including parents/guardians) who picks up a child each week, so please inform anyone who may be picking up your child that they will need photo identification (and so will you!) If you have any questions, please contact Allison Kane at info@tricountytherapy.com
Child's Name:

First NameLast Name
Pick Up Person #1:

First NameLast Name
Relationship to Child:
Phone Number for Pick Up Person #1:

Area CodePhone Number
Driver's License Number:
Driver's License State:
Pick Up Person #1:

First NameLast Name
Relationship to Child:
Phone Number for Pick Up Person #2:

Area CodePhone Number
Driver's License Number:
Driver's License State:
Technology Information and Release Form
The future of the Tri-County Therapy Summer Camps will be determined in part by the successful promotion of the program. We request your assistance in promoting the program by granting permission to use any photographs, videotape or audiotape of your child for our publications, videos or web pages. Please review and sign below to indicate your consent of our use of the photographs, videotapes or audiotapes.

I hereby authorize and consent to the use and reproduction Tri-County Therapy Program of any and all photographs, video tape recordings, or audio tape recordings in which my child appears. I understand I will not receive payment for the photographs, video tape recordings, or audio tape recordings, and the photographs, video tape recordings or audio tape recordings will not discredit or distort my child in any way. All negatives and positives, and tapes, together with the prints shall be solely the property of the Tri-County Therapy, LLC.
Child's Name:

First NameLast Name
I certify I am the parent or guardian of the child named above and give my consent to the use of my child’s name and likeness for promotional activities as described above.

First NameLast Name
Date

MonthDayYear
Date
Parent or Guardian Signature:

Clear
Should be Empty:

Summer Camp Registration

Medical History

Developmental/Educational History

Pick Up Permission Form

Technology Information and Release Form