Inclusion For All™

Dedicated to including ALL people with special needs™

The Camp-For-All™ Information Center

The complete resource to help parents and professionals include ALL kids in summer camp

Provided by Jewish Community Center of Cleveland, 26001 S. Woodland Road, Beachwood, Ohio, 44122

Participant Profile

Child’s Name Date of Birth

Completed by

Home Phone

Work Phone

Family Background

Parent/Guardian Status: _divorced _ married __ separated _single____widowed

Number of Siblings________ Ages____________________

Are any of the siblings attending JCC camps? _______________________________________

Do the siblings have special needs? ________________________________________________

Do you have any pets? __________________________________________________________

Recreation

What type of recreational activities does your child enjoy?

________________________________________________________________________________________________________________________

Please name any activities that your child is especially excited about participating in at camp.

________________________________________________________________________________________________________________________

Does your child enjoy swimming? Horseback riding?

________________________________________________________________________________________________________________________

Are there recreational activities that tend to evoke anxious feelings in your child? How do you help to reduce the anxiety? (singing, reading)

________________________________________________________________________________________________________________________

Communication

Is your child able to express his/her needs? Please explain

________________________________________________________________________________________________________________________

Please list any effective key words/phrases

________________________________________________________________________________________________________________________

Does your child: ___________Read lips Use a communication board? Use any signs?

Please explain: ___________________________________________________________

________________________________________________________________________

Behavior

Please describe your child’s behavior:

________________________________________________________________________________________________________________________

Please describe the behavioral management program used at home and at school.

________________________________________________________________________________________________________________________

What are your recommendations for the JCC staff in handling behavioral problems that may arise?

________________________________________________________________________________________________________________________

Socialization

How does the child interact with peers in a group setting?

________________________________________________________________________________________________________________________

How well does he/she listen and follow directions?

________________________________________________________________________________________________________________________

Does your child get bored easily? Would your child benefit from a schedule?

________________________________________________________________________________________________________________________

Can the child finish a task in a given time period?

________________________________________________________________________________________________________________________

Please rate your child’s physical capabilities:

Excellent Good Fair Poor

Balance

Hand/Eye Coordination

Craft Ability

Kicking/Throwing

Swimming

Jumping/ Running

Does your child have a physical disability or any physical limitations?

________________________________________________________________________________________________________________________

Is any special equipment required?

________________________________________________________________________________________________________________________

Does your child have any allergies?

________________________________________________________________________________________________________________________

Are there any dietary restrictions?

________________________________________________________________________________________________________________________

Does your child take medication? Will they take medication while at camp?

________________________________________________________________________________________________________________________

Please describe your child’s daily living skills:

Independent Requires verbal Requires verbal and

prompting only physical prompting

Eating

Bathroom Skills

Dressing/Changing into Bathing Suit

Brushing Teeth

Comments

________________________________________________________________________________________________________________________

Please describe your child’s preferred recreational activities. Please include activities that are especially rewarding, soothing, or meaningful.

________________________________________________________________________________________________________________________

What type of year round JCC programming would benefit your child socially and recreationally?

________________________________________________________________________________________________________________________

Please use the space below to share any information you feel would be beneficial to ensuring a safe, successful and appropriate summer experience for your child. You may also call Dana, at 216.382.4000 ext. 294.

________________________________________________________________________________________________________________________

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Inclusion For All™

Dedicated to including ALL people with special needs™

The Camp-For-All™ Information Center

Provided by Jewish Community Center of Cleveland, 26001 S. Woodland Road, Beachwood, Ohio, 44122

Participant Profile

Completed by

Family Background

Parent/Guardian Status: ___divorced ___ married ____ separated ___single____widowed

Recreation

Communication

Parent/Guardian Status: _divorced _ married __ separated _single____widowed