Wufoo

Take2 Summer Camp Application

Take2 Summer Camp will notify parents of children's admission by April 1, 2012. In addition to the application, children may be asked to come for a low-key playdate before admission decisions are made. Priority is based on order of receipt of application as well as the candidate's fit/match with the group.

Take2 does not discriminate on the basis of race, color, gender, religion, national origin, class, or sexual orientation, and encourages applications from families across the economic spectrum. Scholarships are available to facilitate participation.

Child Information
First Name *
Last Name *
Male/Female *
Age as 6/1/2012 *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent/Guardian Information
Child lives with *
Parent/Guardian Name *
Relationship to child *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Number * ### - ### - ####
Work Phone Number ### - ### - ####
Where is it easiest to reach you? *
Email *
Business Name
Parent/Guardian 2 Name
Relationship to chld
Address (if different from above)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number, Home ### - ### - ####
Phone Number, Work ### - ### - ####
Where is it easiest to reach you?
Email
Business Name
Siblings or other significant family members in the home (state name, gender, age, and relationship to applicant) *
School Information
Child's current school *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Is your child in a special education program? *
What kinds of special services, if any, does your child receive, both at school and outside of school? *
Occupational Therapy Speech/Language Therapy Aid in classroom Pull-out services IEP Other None
Health/Medical
Child's Pediatrician *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Insurance *
Policy Number *
Is your child currently taking any medications? If so, please list including dose and time taken. *

Please write N/A if this question is not applicable to your child
What is your child's current/most recent diagnosis? Who made the diagnois? *

Please answer the question completely. Please enter N/A if the question is not applicable.
Please list any of your child's significant health conditions *
Please list any of your child's allergies *
Please list any of your child's special diet/food restrictions.
Please list any of your child's limitations or concerns *
Please describe any behavioral difficulties that your child has (e.g. hitting, biting, self-injurious behaviors, etc.). Please be specific. Withholding information may hinder our ability to handle any crises or challenging situations. *
Service Provider Information

Please provide information regarding current services. If you agree to allow us to talk to your provider, please download and sign the release form from the Take2 website and send it to us).
Please check any services that your child receives *
Therapy (individual/group) Psychiatrist/Medicating physician Speech Services Occupational Therapy Social Skills Training Other None
Please list any providers, dates of service, frequency (how often), and contact information - if we may talk to the provider *
Important Information About Your Child
What special interests and strengths does your child have? *
What are your child's current areas of need or challenges? *
What has been done so far to try to meet the needs of your child? *
Does your child know his/her diagnosis? How do you manage this in your family? *
Please add anything else you think we need to know about your child.
Please attach your child's IEP, if available.
Please attach your child's neurological/psychological evaluation, if available.
Please attach any other document that you feel would be helpful to us in making our decision.
Digital Signatures
Parent/Guardian 1

I/We hereby make an application for my/our child to attend Take2 Camp. I/We have filled out all of the information to the best of my/our knowledge. I/We realize that this is simply an application and that my child has not at this time been accepted to Take2 Camp.

Please write your name below. *
Date MM / DD / YYYY
Parent/Guardian 2

I/We hereby make an application for my/our child to attend Take2 Camp. I/We have filled out all of the information to the best of my/our knowledge. I/We realize that this is simply an application and that my child has not at this time been accepted to Take2 Camp.

Please write your name below.
Date MM / DD / YYYY
How did you hear about us?
Do Not Fill This Out

Wufoo

Child Information

Parent/Guardian Information

School Information

Health/Medical

Service Provider Information

Important Information About Your Child

Digital Signatures