March Break Application Form

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March Break Application Form

MARCH BREAK RESPITE DAY CAMP

APPLICATION FORM

REGISTRATION INFORMATION

March Break Respite Day Camp 2021: March 15th – 19th
Morning Session: 8:30am-12:00pm
Afternoon Session: 1:00pm-4:30pm
$25 for the week

*Please note that your child must be registered for either all morning sessions or all afternoon sessions, and cannot attend both unless there are spots still available.

Please complete the following form if you are interested in having your child attend the 2021 Yarmouth Association for Residential Community Options March Break Respite Day Camp. Once you submit your registration, please await a confirmation of approval email that your child is able to attend camp. Due to limited group capacity for participants, registration will be assigned on a first come first serve basis. YACRO Respite Day Camp is open to school aged children living with physical/mental disabilities/illnesses.

ATTENDANCE PREFERENCE *

Morning Session: 8:30am-12:00pm
Afternoon Session: 1:00pm-4:30pm

CHILD AND FAMILY PROFILE

Name *

Date of Birth: *

Source of referral: *

Parent(s)/Guardian(s) Name(s): *

Primary Phone Number: *

Secondary Phone Number:

Email Address: *

Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

I consent to Respite Day Camp Staff sending text information regarding my child to my phone *

Emergency Contact Name(s): *

Emergency Contact Phone Number 1 *

Emergency Contact Phone Number 2

CHILD INFORMATION

Please take the time to answer carefully these questions

*Most answers are compulsory. If a question does not apply, please just type "n/a" in the text box.

Family Doctor: *

Other Professionals Involved: *

Diagnosis: *

Allergies: *

Medical Needs: *

Medications: *

Specific Concerns:

Please indicate the level of care that your child requires: *

heavy
moderate
light

Does your child require assistance with personal care? *

Please specify what aspects of personal care your child requires assistance with: *

Communication

Please describe your child’s method(s) of communication: *

Behaviors

Please describe what behaviors can be expected from your child: *

Methodology

Please specify what methods are used when problematic situations occur (ie. behavior and medical problems): *

Daily Routine

Please describe a regular day in the life of your child. Please include time of awakening, mealtimes, activities, personal care schedules and bedtimes: *

Activities/Hobbies

What are your child’s favorite activities? For example, do they enjoy music, certain television programs, a special toy or book, etc.? *

Outdoor Recreational Activities

What types of outdoor activities does your child enjoy? *

Other

Please comment on any additional information that you feel is important for quality care of your child:

Parent/Guardian Signature/Consent:

*By typing my name, I consent to sharing the above information regarding my child with the Respite Coordinator and Respite Day Camp Staff.

Parent/Guardian Signature/Consent: *

Return to Respite Page

Return to Respite Page

Return to Respite Page

For more information regarding respite support please contact:

Amy Sarginson

Respite Coordinator, Western Region

(902) 742-9258

(902) 742-0156

6 Thurston Street, Yarmouth, NS,
B5A 4K5

respite@yacro.com

Contact Us

Reach out to us for any questions or concerns.

For more information regarding respite support please contact:

Amy Sarginson

Respite Coordinator, Western Region

(902) 742-9258

(902) 742-0156

6 Thurston Street, Yarmouth, NS,
B5A 4K5

respite@yacro.com

Contact Us

Reach out to us for any questions or concerns.

March Break Application Form

March Break Application Form

MARCH BREAK RESPITE DAY CAMP

APPLICATION FORM

REGISTRATION INFORMATION

CHILD AND FAMILY PROFILE

CHILD INFORMATION

Please take the time to answer carefully these questions

Communication

Behaviors

Methodology

Daily Routine

Activities/Hobbies

Outdoor Recreational Activities

Other

Parent/Guardian Signature/Consent:

Copyright 2021 YACRO © All Rights Reserved

For more information regarding respite support please contact:

Amy Sarginson

Contact Us

For more information regarding respite support please contact:

Amy Sarginson

Contact Us