Rainbow's End Camper Personal Information

Camper Personal Information

Rainbow's End Day Camp
Camper's Name*

First NameLast Name
Nickname (if applicable)
Contact Person*

First NameLast Name
Relationship to Camper*
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address for Contact Person*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian*

First NameLast Name
Legal Guardian's Relationship to Camper*
Legal Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Case Worker

First NameLast Name
Case Worker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact #1*

First NameLast Name
Contact #2*

First NameLast Name
Contact #1 - Relationship to Camper*
Contact #2 - Relationship to Camper*
Contact #1 - Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Contact #2 - Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Contact #1 - Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Contact #2 - Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Contact #1 - Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Contact #2 - Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Diagnosis*
Secondary/Other Diagnosis
Other Conditions/Concerns (including psychiatric)

In the following sections, please check as many statements that apply. Check as many as are needed, unless otherwise specified. Please answer thoroughly giving examples where applicable.
MOBILITY*

Walks/Runs IndependentlyNeeds Assistance Walking/RunningNeeds Assistance on StepsUses a WalkerWears AFO/Braces on LegsUses a Wheelchair
If camper uses a wheelchair, please describe transfer procedures.
ACTIVITY LEVEL*

Has typical attention span for his/her ageHas a very short attention spanIs under active (needs motivation to participate)Is overactiveIs easily distracted by sights, sounds, people, etc
Please describe how you manage his/her activity level, motivate him/her to participate, etc.
Is the camper able to stay with a group throughout the day, or do they have a tendency to wander?*

Stays with a group throughout the dayTendency to wander
If wanders, what are ways to redirect their attention?

TOILETING

Rows	Check all that apply	Please list any special needs or assistance typically provided
Uses toilet independently
Needs to be reminded
Needs some assistance with toileting
Uses the toilet on a schedule
Needs catheterization (assisted, self care)
Is independent in menstrual care (if applicable)
Does not use toilet at all (uses incontinent briefs, diapers, etc)
Does he/she communicate bathroom needs? If yes, how?

COMMUNICATION SKILLS

Rows	Check all that apply	Please list any special needs or assistance typically provided
Uses verbal communication
Doesn’t verbally communicate
Uses sign language
Understands sign language
Writes to communicate
Able to read written communication
Uses/understands gestures, points, etc.
Uses pictures or word cards
Uses adaptive systems such as communication board

DRESSING (for use at the pool)

Rows	Check all that apply	Please list any special needs or assistance typically provided
Has no difficulty (un)dressing
Needs assistance (un)dressing
Can put on Underwear
Can put on Socks
Can put on Shirt
Can put on Pants
Can Button
Can Snap
Can Zip
Can Tie shoes

MEALTIMES

Rows	Check all that apply	Please list any special needs or assistance typically provided
Has a poor appetite
Has a good appetite
Has difficulty with choking or swallowing
Has history of throwing or grabbing food, etc.
Has other special dietary needs (no sugar, no meat, small pieces, etc.)
Has specific food allergies/sensitivities

ACTIVITIES

Rows	Check all that apply	Please list any special needs or assistance typically provided
Camper swims well
Camper cannot swim, but will go in water
Camper needs life jacket
Camper has very sun-sensitive skin
Does camper have any favorite activities? If so, please list them.
Does camper have any indoor games/activities that they like (playing cards, painting, watching movies, etc.). If so, please list them.
Does the camper have any activities they don't like? If so, please list them.
Does the camper have any favorite outdoor activities they like? If so, please list them.
Do you have anything you feel may be pertinent to your child’s camp experience? If so, please list.

BEHAVIOR

Rows	Check all that apply	Please list any special needs or assistance typically provided
Bites others
Scratches, pinches
Hits others
Grabs other people
Uses in-appropriate touch
Uses in-appropriate words
Runs away
Doesn’t like to be touched
Prefers to be alone
Afraid of loud noises
Other challenging behaviors we should know about? If so, please describe.
Is the challenging behavior(s) usually the result of a trigger(s)? If so, please describe.
Are there effective responses to challenging behaviors? If so, please describe.
Is the behavior corrected with a reward(s)? If so, please list two or three effective rewards.