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Summer Day Camp Application

Parent Information

Camper Information

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

Step 1: Submit Application

Step 2: Send $25.00 Refundable Registration fee
by PayPal to Hart of Autism

*Refunded if attend both days of camp

Waiting Room

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