Kids Camp Registration Form

Thank you for joining us for Kids Camp! Please remember to register each child individually. All children are welcome to attend.

Your Name *

Email *

Phone Number *

Child's Name *

Date of Birth *

Child's Gender *

Parent's Mailing Address *

Name of Emergency Contact/Pick Up Person *

Emergency Contact Phone Number *

Relationship to child *

Will this person be on site? *

Name of 2nd Emergency Contact/Pick Up Person

Phone Number

Relationship to child

Will this person to be on site?

How does your child handle transitions? *

Are there any strategies that help your child with transitions?

What helps your child feel comforted when upset or anxious? *

Does your child generally nap during the day? *

If so, how do you know when they're sleepy? How long do they sleep? Do they need any items to help them sleep?

Does your child require support while eating? If so, what kind of support? *

Are there any foods you do NOT want us to offer your child? *

Is your child on a special diet? If yes, please explain. *

What does your child eat with? *

Spoon

Fork

Hands

N/A

What does your child use to drink? *

Bottle

Sippy Cup

Cup with Straw/Lid

Open Cup

N/A

What does your child wear during the day? *

Is your child potty training? *

If potty trained, do you consent to allow Beyond Blindness staff (not volunteers) to take your child to the restroom?

What is your child's favorite song, toy, or object? *

How does your child enjoy playing with others? *

What activities does your child enjoy? *

What best describes your child? (Select all that apply) *

Scooting

Crawling

Walking

Wheelchair User

Non-Ambulatory

Uses Assistive Walking Equipment

Experiencing Developmental Delays

Typical

Blind

Visually Impaired

Deaf

Hard of Hearing

How does your child communicate? *

If communication device or other, please explain.

Does your child have any sensory sensitivities? Please explain. *

Does your child have any behavioral challenges or social/emotional needs? Please explain. *

What languages are spoken at home? *

Please list any allergies (food, environmental, medication, etc.) *

Does your child have any acute health concerns? Please explain. *

Does your child need to take any medication during our program? If so, what time? We will text for you to come administer the medication.

Does your child require an EpiPen or any other emergency medical devices? Please explain. *

What diagnoses does your child have (if any)? *

Do you consent to your child's photo being taken and used by Project Alive for promotional materials? *

Do you understand that a parent/guardian must be reachable by text or phone call at all times during child care and that a parent/guardian will need to perform all toileting duties? *

Do you consent to an electronic signature? *

Type your full name here to sign. *

Register one child at a time please!