FunAbilities/SLYP-OUT Winter and Spring 2015
Please check:
☐ FunAbilities: Elementary School Aged
☐ SLYP-Out :
High School Aged
Participant’s name:
Date of Birth (yyyy/mm/dd):
Parent/Guardian Name(s):
Email:
Address:
Phone Number: (Home)
(Cell)
Emergency Contact: (Name)
(Phone number)
Health Card Number:
Doctor’s Name:
Doctor’s Phone Number:
Medications Taken:
Accommodations / Assistive Devices Required:
*(See “Quick Reference” attached to help provide more information about your child)
Who will be dropping off/picking up your child?
Name: ____________________________________ Phone number : _____________________________
Y:\PROGRAM\Avocational\Summer Fun\Summer Fun SLYP-Out 2014 - Registration.docx
_
□
I hereby give permission for my child to go on fieldtrips ( walks, for ice cream, park, etc.), accompanied
by FunAbilities/SLYP-Out staff.
□
I hereby grant and release to Saskatchewan Abilities Council the right to use photographs, audio
tapes and/or videotapes in which my child (children) appear in any information, promotional and/or
marketing materials such as videos, films, recordings, still photographs, digital images, social media
(Facebook, websites) or articles relating to Summer Fun/SLYP-OUT, its programs and services.
Parent/Guardian signature:
Fees: $100.00 or $10.00 drop-in
☐ Cheque payable to Saskatchewan Abilities Council
☐ Master Card / Visa / Debit
☐ Cash
PLEASE NOTE: Saskatchewan Abilities Council does not provide one-one-one support. However,
support workers and companions are more than welcome to attend the program with your child.
Companion Required: Yes☐
No☐
Reason:
Physical ☐
Medical ☐
Behavioural ☐
Name of Companion Attending:
Participants of FunAbilities/SLYP-OUT will require an individual support worker (companion) to accompany them
to the program if they require assistance due to: aggression, inability to follow directions, putting themselves or
others at risk. A companion must be at least 18 years of age or older and must agree to assume full responsibility
for the participant’s medical, physical, and/or behavioral needs while engaged in any activity. A companion may
be a family member, friend, support worker, or case worker.
Please return application to:
Y:\PROGRAM\Avocational\ SLYP-Out 2014 - Registration.docx
Saskatchewan Abilities Council
Box 5011; 162 Ball Road
YORKTON SK S3N 3Z4
Phone: 306-782-2463
tmeszaros@abilitiescouncil.sk.ca
FunAbilities/SLYP-Out Quick Reference
Name:
Program(s):
Likes: (food, objects, toys,
Must Haves:
Date:
Dislikes:
No Ways:
activities, sensory)
What Calms: (relaxation
strategies, objects, toys)
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
Communication:
Personal Care Needs:
Diet: (special diets, feeding
Community Safety: (needs
(words, gestures, sounds)
(toileting, dressing)
assistance, etc.)
extra assist, hold hand, safe on
transit?)
Epi-Pen left at the Centre
Carries Epi-Pen
Expressive:
Receptive:
-
-
-
-
Strengths, interests, abilities:
-
-
1.
2.
3.
4.
5.
6.
7.
8.
Allergies:
-
Program Goals:
1.
2.
3.
Y:\PROGRAM\Avocational\SLYP-Out 2014 - Registration.docx
When in pain/discomfort participant will usually:
When anxious/upset participant will usually:
-
To help participant achieve goals, the Program Staff can: (first/then)
-