Interest Form Entry

Sports Camp Buddy Ministry Interest Form

Parent Information

First

Last

Phone Number

Child Information

First Name

Last Name

Birthdate

/ /

Nature of child's disability (including the name of syndrome, if known)

What is the degree of severity of the disability?

Mild Moderate Profound

Primary modality for feeding?

Mouth NG tube G tube

Child's level of toileting:

Independent Needs Assistance

How does your child communicate?

Please share any behaviors of which we should be aware. Specify what the behavior looks like (screaming, dropping, biting, scratching, etc.) rather than giving general descriptions (angry, upset):

Please list any medical concerns or conditions that could be affected during sports camp. (i.e. flashing lights triggering seizures, orthotics, etc)

Submit