Summer Camp 2024 Registration Form - The Behaviour Change Clinic

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About Us
- Our Approach
Services
Social Skills
Contact Us
- Employment and Volunteer Opportunities

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Summer Camp 2024 Registration

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 ($700) - WAITLIST July 2-5 AM ONLY ($340) - WAITLIST July 2-5 PM ONLY ($340) - 2 SPACES July 8-12 Full day ($875) - 2 SPACES

Will your child require 1:1 support?

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.