CAMP ATLANTIC PERSONAL INFORMATION FORM

Date  

Name

E-Mail Address

Gender choose Male Female

Age

Birthday

What is the camper's diagnosis (Mental Retardation, Attention Deficit, etc.)

PLEASE DESCRIBE THE CAMPER AS OBJECTIVELY AS POSSIBLE:

Relationships with others:

Self discipline:

Emotional stability:

Impulse Control:

Awareness of Abilities:

Awareness of limitations:

Self help skills (dressing, eating, bathing):

Describe limitations:

Effective behavioral techniques:

Allergies:

Skills (Choose a 1-5 rating with 1 being low and 5 being high)

Money 0 1 2 3 4 5 Writing 0 1 2 3 4 5 Phone conversation 0 1 2 3 4 5 Dialing 911 or family number 0 1 2 3 4 5

Crossing the street 0 1 2 3 4 5 Putting on seat belt 0 1 2 3 4 5 Use of Public Bus 0 1 2 3 4 5

House chores Makes own bed 0 1 2 3 4 5 Brushes teeth 0 1 2 3 4 5 Grooms hair 0 1 2 3 4 5 Showers self 0 1 2 3 4 5

Expresses needs verbally 0 1 2 3 4 5 Keeps clothes organized 0 1 2 3 4 5 Remembers medicine schedule 0 1 2 3 4 5

Follows directions 0 1 2 3 4 5 Accepts supervision from females 0 1 2 3 4 5 Accept supervision from males 0 1 2 3 4 5

Does applicant have any special interests? Explain:

Is the applicant able to swim? Choose Yes No

How well?

Please identify the goals, objectives, hopes you wish to see realize while the applicant participates in the Camp Atlantic program:

Other information:

CAMP ATLANTIC AGENCY INFORMATION

Name of responsible person

Office hours

Telephone

Agency name

Agency Address

Zip Code

Billing information:

Send Bill to:

Billing procedures of agency:

List of persons attending Camp Atlantic to be funded by the agency above: