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Summer Day Camp Application
Parent Information
Camper Information
Shirt Size
Functionality Rating Scale FRS Scoring Instructions: Please indicate the level of instruction or ability for the child. Comments section is to be used for further details or explanations.
Body Movement
*
Normal Movement
Limited Movement
Severely Limited
No Movement
Feeding Assistance
Independent
Minimal
Partial
Complete Assistance
Toileting Assistance
*
Independent
Minimal
Partial
Complete assistance
Level of Functioning
*
Completely Independent
Independent in special environment
Moderately dependent
Totally dependent
Interations with others
*
Fully Capable
SItuational Limitations
Extremely Limited
Unable to engae with others
Supervision for Public Outing
Stays with group with no help
Verbal Prompting Only
Hand Held Required
Complete Supervison Reuired
Communication Ablitiy
*
Normal with same age peers
Slightly Delayed
Markedly Delayed
Incomprehensible/none
Submit
Step 1: Submit Application
Step 2: Send $25.00 Refundable Registration fee
by
PayPal to Hart of Autism
*Refunded if attend all 3 days of camp
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