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Parent/Guardian Information

Primary Caregiver *

Relationship

Address 1

Address 2

City

State/Province

Zip

Email *

Phone *

Emergency Contact Information

Emergency Contact's Name

Relationship to Camper

Emergency Contact Address

Emergency Contact Phone

Emergency Contact Email

Camp Location: Tucker Lekotek

1901 Montreal Road, Suite 126, Tucker, GA 30084

CAMP DATES AND TIMES

Camp Session Requested (1st choice)

Session 1: June 24-27, 9:30 am - Noon (ages 4-9)
Session 2: June 24-27, 1:30 - 4:00 pm (ages 4-9)
Session 3: July 8-11, 9:30 am - Noon (ages 4-9)
Session 4: July 8-11, 1:30 - 4:00 pm (ages 6-11)

In the event that your requested session is full, can your child/children attend another session? (please indicate all sessions that will work)

Yes, Session 1: June 24-27, 9:30 am - Noon (ages 4-9)
Yes, Session 2: June 24-27, 1:30 - 4:00 pm (ages 4-9)
Yes, Session 3: July 8-11, 9:30 am - Noon (ages 4-9)
Yes, Session 4: July 8-11, 1:30 - 4:00 pm (ages 6-11)
No, only the requested session above works for my family.

Please provide any additional information regarding your availability to attend camp. Camp is 4 days, Monday-Thursday.

How many children will attend camp? (Please include your camper with special needs and any siblings who will attend) *

Camper Information

Camper First Name

Camper Last Name

Camper Birthdate

Camper's Known Allergies

Camper's Tshirt Size *

Youth Small
Youth Medium
Youth Large
Youth Extra Large
Adult Small
Adult Medium
Adult Large

Camper Care

What is your child's special need (please include additional information that you feel we should know)

Does your child have a seizure disorder? *

Yes
No

If yes, what type of seizure?

And are the seizures controlled with medication?

Yes
No

Please provide any additional information about your child's seizures (ie: triggered by light, how long seizures last, when medical intervention is needed, etc.)

My child is best positioned:

in a regular chair
seated on the floor
in a wheelchair with tray
in a corner chair with tray
in a cube chair
lying down

My child wears glasses?

Yes
No

My child wears hearing aids?

Yes
No

My child communicates

with speech
with sign language
with a communication device
by pointing
using other methods

Please provide additional information about your child's communication needs. (If he/she will bring a communication device, specific signs he/she uses, or other helpful information.

My child is

right dominant
left dominant

Does your child have experience with technology (computer, iPad, tablet etc.)?

Yes
No

Please indicate how your child best accesses the computer or iPad. (multiple modes may be selected)

Regular computer mouse
Touch Screen
Switch
Trackball
EyeGaze
Not Sure

My child's favorite computer/iPad games are:

Please select any or all of the statements below that apply to your child's behavior

Tends to wander or leave the group
Has agressive tendencies
Has self-injurious tendencies
Has required physical restraint to ensure safety in the last 12 months
N/A

If you selected any of the boxes above, please explain:

If upset, is there a particular thing that calms your child (rocking, singing, holding, etc.)? Please explain:

Please indicate your child's toileting needs below: *

My child will indicate and is independent with toileting
My child will not indicate, please take at snack time.
My child wears diapers (please send diapers if needed during camp)

Please explain any additional toileting needs

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Neon CRM by Neon One

Parent/Guardian Information

Emergency Contact Information

Camp Location: Tucker Lekotek

CAMP DATES AND TIMES

Camper Information

Camper Care

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Parent/Guardian Information

Emergency Contact Information

Camp Location: Tucker Lekotek

CAMP DATES AND TIMES

Camper Information

Camper Care