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Day Camp Application
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Parent Information
Camper Information
Shirt Size
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
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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 $35.00 Non-refundable Registration fee
by
PayPal to Hart of Autism, Click here to submit
or Mail check payable to
Hart of Autism, PO Box 84, Munfordville KY 42765
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