, Ottawa
CAMP KALEIDOSCOPE
CAMPER APPLICATION FOR ASD SUMMER DAY CAMP 2014
Registration Information: Please complete and submit to register interest – intake meeting will be necessary.
Submission of Application form to Children at Risk:
By mail at: Children at Risk, 235 Donald Street, Suite 209, Ottawa, ON, K1K 1N1
By email to: car@childrenatrisk.ca
By Fax: 613-741-5530
Camp Location: Lester B. Pearson Catholic High School, 2072 Jasmine Crescent (at Ogilvy), East-Central Ottawa.
Camp Fees: $350 for 5-day weeks, $280 for the 4-day week (August 5-8)
*NEW* - Only 3 weeks can be offered at above subsidized price – additional weeks may be offered
(contingent upon camper’s needs, staff availability & funding) at $500/week ($400 for 4-day week, Aug 5-8)
Ages: 4-20+ Subject to responses received, as only 40 participants per week.
How many weeks of Camp are you looking for in total? Number: ______
State preference of weeks i.e 1,2 ,3 or √ if no preference….availability dependent on demand
July 7-11
July 28-August 1
July 14-18
August 5-8
July 21-25
Camper Information:
Name:
Date of Birth (D/M/Y):
Address:
City:
School:
Diagnosis
Medications? YES/NO
Other Medical Considerations
Gender:
Age:
Postal Code:
Grade Completed:
Parent/Guardian Information:
Contact #1:
Name:
Address: (if different)
City:
Phone number:
Email:
Contact #2:
Name:
Address: (if different)
City:
Phone number:
For Office Use only:
Relationship:
Postal Code:
Work/Cell Phone:
Relationship:
Postal Code:
Work/Cell Phone:
2
Please tell us about your child:
Please answer the questions below giving relevant details (take as much space as you need)
Has your child attended ANY camps before?
If yes, which ones and year?
YES
NO
Does your child need one-on-one support?
If Yes please state why?
YES
NO
Is your child able to travel on a school bus?
YES
NO
…. YES
NO
Has your child been physically aggressive toward others?
How?
YES
NO
Is your child a runner?
Are they attracted to run to anything in particular?
YES
NO
Does your child have good spoken language skills?
If not how do they communicate?
YES
NO
Does your child need assistance toileting/eating?
Please give details as to which one and the extent?
YES
NO
Does your child engage well with other youth his age?
If no, describe his interactions?
Does your child have any physical issues that would prevent them participating in certain activities?
Please detail any allergies, food restrictions and if your child is on a GF/CF diet?
Does your child have anxiety or strong fears of anything in particular?
Is there anything else we should know in considering your child for Camp Kaleidoscope 2014?
235 Donald Street, Suite 209  Ottawa, Ontario K1K 1N1  Tel. (613) 741-8255  Fax (613) 741-5530
A Registered Charity  No. 10691/3775/RR/0001 www.childrenatrisk.ca  car@childrenatrisk.ca