Summer Camp 2024 Registration Email Child's full name Child's date of birth Parent/Guardian Name Address Emergency Telephone number How will you be paying? Autism Funding Cheque/Cash Which dates and times would you like to register for? July 2-5 Full day ($800) July 2-5 AM ONLY ($440) July 2-5 PM ONLY ($440) July 8-12 Full day ($1000) July 8-12 AM ONLY ($550) July 8-12 PM ONLY ($550) Will your child require 1:1 support? Yes No Child Information Does your child have any allergies or medical conditions that we should be aware of? If yes, please describe. Will your child be taking any medication during group time? Yes No Other How does your child communicate? Vocal/Verbal Minimally verbal AAC Others Please upload your child's IEP What are your child's interests? What motivates him/her? Does your child engage in any of the following behaviours? Hitting/Kicking/Punching others Bolting Limited awareness of safety Self-injury Biting None of the above Waivers and Releases I understand that the child to adult ratio during group time is 4:1 and I agree that my child does not engage in severe distressed behaviour that poses a risk to themselves or others. Yes, I agree No, I do not agree I am aware that there are risks associated with the participation in Let's Play!, including the risk of injury, and I consent to my child’s participation in spite of such risks. I acknowledge that it is my responsibility to advise The Behaviour Change Clinic of any medical or other conditions which may affect my child’s participation in Let's Play! and have listed them above. I understand that I am responsible for immediately notifying staff/supervisor of any changes to the above information. In the event that my child requires medical attention, I consent to my child being transported to the nearest emergency centre, including by ambulance if necessary. I have read this form and understand and accept its terms. Yes, I agree No, I do not agree I consent to The Behaviour Change Clinic taking photos and/or videos of my child for advertising and/or training purposes. Yes, I agree No, I do not agree I understand that either myself or a designated contact will pick my child up from their group on time. Late pick ups are charged at a rate of $65/hr. Yes, I agree No, I do not agree I acknowledge that there are no refunds should my child be removed from the group and/or be unable to attend sessions. Yes, I agree No, I do not agree I have checked my child's funding and confirm there is enough remaining to pay for the group. I agree to pay a $150 service fee if my RTP is rejected due to lack of funds. Yes, I agree No, I do not agree Send
