HEALTHYUNOW FOUNDATION CAMP REGISTRATION

One registration form per participant. Please print.

Must be completed in its entirety by a parent or legal guardian.
Selection for participants will be on a first come, first serve basis.
Payment must be submitted with this registration request.

HealthyUNow Foundation does not discriminate on the basis of race, color, gender, religion, national origin, class or sexual orientation.

Participant Information
First Name: ________________________ Last Name: ____________________________ Nickname: _________________________
______

Current Grade in School: __________

Home Address: _______________________________________________________________________________________

City: ____________________________________________________________ State: ___________ Zip: ____________
Parent/Guardian information

Parent/Guardian 1 (Lives in Camper Home) First Name: _______________________ Last Name: __________________________

-Parent
Email: ____________________________________ Cell: __________________ Home: ________________ Work: _____________
We require at least one parent/guardian email address to which we can send important information and updates.
Parent/Guardian 2
If No, Give Address: _________________________________________________ City: _________________ State: ___ Zip: ______

Email: _____________________________________ Cell: __________________ Home: ________________ Work: _____________

Check if this p
Pickup Authorizations / Emergency Contact Information / Contact Permissions

If yes, please explain in detail. _________________________________________________________________________________

Please indicate two people other than a parent/guardian who we may contact in case of emergency, or if your camper needs to leave
camp early and a parent/guardian is not available. These names will be added to the campers authorized pick-ups, unless we are
notified otherwise. DO NOT LEAVE BLANK.
1. First & Last Name:_____________________________________ Relationship to Camper: _______________________________
Lives in (city/state): ________________________ Cell #: ________________ Home #: _____________ Work #: _______________

2. First & Last Name: _______________________________________ Relationship to Camper:__________________ __________

Lives in (city/state): _____________________________ Cell #: _______________ Home #: ___________ Work #: _____________
Please provide a list of any additional persons (not already listed above) who have permission to pick up your camper from camp.
For your childs safety, these are the ONLY people who will be allowed to pick up your child, unless we receive a written note ahead of time from the
parent/guardian giving authorization. Please write NONE if you do not have any additional names. Attach additional paper if necessary.

Name

Relationship to Camper

Home Phone

Work Phone

Cell Phone

Nomination
This section must be completed.
What teacher or therapist is nominating your child for participation?_____________________________________________________
How may we contact them? Work # ______________________________

Cell # ________________________________________

Email: ______________________________________________________________________________________________
Program Survey
How did you hear about the HealthyUNow Foundations Drama Camp program?
____________________________________________________________________________________________________________
What is your reason for choosing this Drama Camp program?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Health/Medical

Physician's Name: _______________________________________________________ Phone: _______________________________

Address: ____________________________________________________________________________________________________
Insurance______________________________________________________ Policy #______________________________________
Is the participant covered under this health insurance company:

YES

NO

Please answer the following questions completely. Please enter N/A if any of the below are not applicable either in general or for this
camp.
Significant health conditions:___________________________________________________________________________________
Allergies:___________________________________________________________________________________________________

Special diet/food restrictions____________________________________________________________________________________

Any limitations or concerns_____________________________________________________________________________________
Is there any other information you would like to give us about your child to help us better care for him/her?
___________________________________________________________________________________________________________
List the medications participant is currently taking including dose and time:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Will the participant be taking medication during Camp?

YES**

NO

**If yes, list the medication(s) to be taken and sign below if you authorize HealthyUNow Foundations on-site staff to oversee the dispensing of
authorized medication.**

List authorized medications participant will be taking: ________________________________________________________________

**I authorize the HealthyUNow Foundations on-site staff to oversee the dispensing of the authorized medication listed above:
____________________________________________________________________________________________________________
Parent/Guardian Signature
CAMPER SCHOOL/LEARNING BACKGROUND
1. At school, does your camper
have an I.E.P./similar?

currently

participate in a group

_______________________

take sensory/other classroom breaks?

__________________________

Receive OT or PT services?

_____________________________

2. Has your camper been suspended or expelled from school at any time?
2a. If yes, when/for how long? What were the circumstances? __________________________________________________________

3. Please indicate if your camper has any specific learning disabilities/difficulties:

s

__________________________________________________

4. What strategies are most critical to your campers success when engaged in a learning activity?
Positive Reinforcement Program
-over-hand instruction

in the learning environment

out of learning environment
____________________________

4a. Please provide specifics as necessary, including other strategies that you have found to be particularly effective/ineffective.
__________________________________________________________________________________________________

Camper Social, Emotional & Behavioral Background

1. Does your camper have any clinical diagnosis(es)?

Primary Diagnosis: _______________________________ Secondary Diagnosis: _____________________________
1a. If yes who made the diagnosis: _________________________________________________________________
2. Additional Diagnosis(es): Please describe additional recurring non-diagnosed behaviors or any ongoing diagnostic
testing/evaluations, if any:
________________________________________________________________________________________________
3. Under what circumstances does your camper become escalated (anxious/stressed/angry, etc.)? (please check all that apply)
hearing loud noises
in large groups of people
when peers receive more attention
when feeling unheard/not listened to
if not winning at a game
when things are unfair when given multiple options/choices
when asked to take responsibility
for actions
when asked to do a non-preferred activity
other: ____________________________________________________

4. When my child is escalated, he/she usually

fights ( verbally physically)
tries to hurt/damage ( self others property) throws things withdraws/wants to be alone
wants to seek revenge
other:_____________________________________________________________ ________________
4a. Has your camper exhibited other behaviors when escalated?

No

Yes (please explain)

_________________________________________________________________________________________________
5. What strategies most effectively help your camper when working through behavioral incidents/escalations? Please select the option
that best describes your campers reaction to the listed strategy.
Effective/Helpful

Tried, Not Helpful

Further Escalates

Unknown/Not
Tried

Verbal directions/instructions
Quiet time to think, taking space
Immediate reinforcement/consequences
Access to a preferred space
Physical tasks / physically active
Distracting conversation on preferred topic
Access to writing/drawing materials
Calming activity (please specify below)
Sensory intervention/equipment
Hug, hand on shoulder, light physical touch

5a. Please provide specifics as necessary, including other strategies that you have found to be particularly effective/ineffective.
____________________________________________________________________________________________________________
________________________________________________________________________________________
6. How frequently does your camper display aggressive, destructive, or harmful behaviors towards themselves?
daily or every other day

about once per week

every few weeks

once a month

very rarely

never

6a. If applicable, please describe typical circumstances that lead to this behavior.
_________________________________________________________________________________________________

7. How frequently does your camper display aggressive, destructive or harmful behaviors towards others?
daily or every other day

about once per week

every few weeks

once a month

very rarely

never

7a. If applicable, please describe typical circumstances that lead to this behavior.
__________________________________________________________________________________________________
8. Which of the following applies to your campers need for physical intervention* to maintain safety
*Please note: this question does not refer to the use of proactive sensory techniques such as deep pressure massage, etc. Physical Intervention, also
referred to as therapeutic holds or sometimes restraint by professionals, is the intentional holding of another so as to prevent them from hurting
themselves or others or because they need assistance regulating their body.

Has Never Required

Rarely Required

Sometimes Required

Frequently Required

At School?
At Home?
8a. This is a safety concern of particular importance. If applicable, please explain further and give examples of specific instances.
___________________________________________________________________________________________________________
9. Please rate the degree to which these descriptions apply to your camper in comparison to his/her chronological age (or to typicallydeveloping peers in his/her age group). Please circle only one number per description.
0 = Does not apply at all

1 = Rarely applies

2 = Sometimes applies

3 = Often applies

4 = Always/Almost always applies

0 1 2 3 4 Shows interest in age-appropriate activities

0 1 2 3 4 Copes age-appropriately with disappointment

0 1 2 3 4 Has an age-appropriate moral compass

0 1 2 3 4 Communicates using age-level vocabulary

0 1 2 3 4 Shows age-appropriate attachment to adults

0 1 2 3 4 Sexual behaviors/language are age-appropriate

0 1 2 3 4 Has age-appropriate hygiene & self-care skills

0 1 2 3 4 Has age-level ability to self-soothe/calm down

0 1 2 3 4 Has age-level fine motor skills

0 1 2 3 4 Has age-level gross motor skills

9a. If your campers chronological age and developmental/social/emotional age are significantly different, please provide any
additional relevant information that we should consider for program participation, group assignments, etc.
_________________________________________________________________________________________________
10. For this question, please rate the degree to which each of these descriptions apply to your camper.
Please circle only one number per description, using the following rating scale:
0 = Does not apply at all

1 = Rarely applies

2 = Sometimes applies

3 = Often applies

4 = Always/Almost always applies

0 1 2 3 4 Has positive outlook on life

0 1 2 3 4 Is willing to try new things

0 1 2 3 4 Takes responsibility for mistakes

0 1 2 3 4 Is easygoing

0 1 2 3 4 Follows instructions with 2 or fewer prompts

0 1 2 3 4 Inappropriately touches others

0 1 2 3 4 Withdraws into fantasy/imagination

0 1 2 3 4 Can see situations from others point of view

0 1 2 3 4 Is able to work independently at projects

0 1 2 3 4 Attempts to manipulate situations

0 1 2 3 4 Transitions well between two activities

0 1 2 3 4 Has an appropriate sense of humor

0 1 2 3 4 Perseverates on a few specific topics

0 1 2 3 4 Is quirky or different than peers

0 1 2 3 4 Successfully takes turns/shares with others

0 1 2 3 4 Tolerates quirky/different behavior in others

0 1 2 3 4 Values the importance of having friends

0 1 2 3 4 Intentionally harms animals

0 1 2 3 4 Has aggressive outbursts

0 1 2 3 4 Makes racial or intolerant threats/statements

0 1 2 3 4 Can accept consequences for behavior

0 1 2 3 4 Reports sequence of events accurately

0 1 2 3 4 Runs away from conflict/difficult discussions

0 1 2 3 4 Steals or hoards items belonging to others

0 1 2 3 4 Shows pride in learning/achievement

0 1 2 3 4 Exhibits sexualized behaviors

0 1 2 3 4 Has a generally stable mood/demeanor

0 1 2 3 4 Has positive relatio nships with peers

0 1 2 3 4 Reads social cues accurately

0 1 2 3 4 Has positive relationships with adults

11. In my childs relationship with peers, he/she:

interacts mostly w/ same age children
prefers being alone
works and plays well with others
interacts mostly w/ younger children
prefers spending time with adults
can follow rules of play (i.e. in games)
interacts mostly w/ with older children
participates in group games if asked
needs to be in charge
12. With other children, my camper makes friendships:
easily and can usually maintain them
slowly/cautiously, then can maintain
easily but has difficulty maintaining
slowly/cautiously, difficulty maintaining

does not really seek out relationships

other:_______________________

13. What level of attention/engagement is your camper usually happy with, compared to other children his/her age?
a reasonable amount of attention
a significant amount of attention
constant attention
13a. What behaviors do you see when your camper is not receiving the amount of attention he/she needs?
__________________________________________________________________________________________________
14. My campers temperament
is typically shy/withdrawn
is usually outgoing/energetic

is usually even tempered

fluctuates frequently

has temper outbursts once in a while

has frequent temper outbursts

PLEASE SIGN THE FOLLOWING PERMISSIONS AND AGREEMENTS PAGE

Permissions & Agreements

Enrollment & Safe Participation:
Applications are accepted dependent upon space availability and determination that HealthyUNow Foundation will be a good fit for
the needs of the individual camper. It is expected that all HealthyUNow Foundation campers are 100% toilet trained. HealthyUNow
Foundation considers the physical and emotional safety of all campers to be paramount; parents/guardians are responsible for
providing complete and accurate information to HealthyUNow Foundation at the time of registration regarding any physical, health,
mental, social, emotional or other individual needs a camper may have.
Campers agree to follow camp policies and procedures and to put forth their best effort towards participating as a member of the
Camp community. HealthyUNow Foundation utilizes parent/guardian support as appropriate when working through
emotional/behavioral challenges with campers, however the Camp Director or his/her designee reserves the right to terminate a childs
stay at camp if his/her safety, or the safety of other campers and/or staff cannot be ensured, or his/her behavior has become disruptive
to the point of precluding other members of the community from a successful camp experience. If a camper is dismissed from camp,
the parent/guardian will be responsible for coming to the camp and picking up the child, or arranging transportation to an appropriate
therapeutic location as soon as is reasonable, exceeding no more than 2 hours from the time the Director informs the parent/guardian
of termination from the program. Dismissal will not result in a refund.
Fees & Payments
Full payment is due with completed application with only two exceptions: (1) if for documented, significant behavioral/therapeutic
reasons it becomes impossible for your child to attend the enrolled session, and/or (2) in the event that HealthyUNow Foundation is
not able to enroll your camper. Once a childs attendance is mutually confirmed by both HealthyUNow Foundation and the
parent/guardian, it will be considered a cancellation if the child withdraws/does not attend.
Release & Permission to Participate
Permission is given for photographs, videos, audio, digital imagery, artwork, etc. of camper to be used on camp (i.e. in cabin photos
and projects) and for future materials (i.e. newsletters, website, yearbook, etc.) originating from the camp. I give permission for my
child to attend HealthyUNow Foundations camp and participate in all activities and programs, which may include activities off the
camp premises and programs supervised by licensed providers of recreational activities as well as participation in year-round events,
programs and activities. HealthyUNow Foundation will observe all reasonable precautions for the care and protection of my child, and
I understand that accidents and injuries may occur in the natural course of participation in such activities. By signing this application, I
hereby release and hold harmless HealthyUNow Foundation, its directors, officers, employees, agents, and representatives, from any
and all damages, claims, injuries and liabilities, which may arise out of my childs attendance at HealthyUNow Foundations camp
and/or his/her participation in any activities while in attendance.

Parent/Guardian Name (Printed): ___________________________________________________

Parent/Guardian Signature: ________________________________________________________

Date: __________________

Thank you for completing this application form and for your interest in HealthyUNow Foundations Camp

HealthyUNow Foundation ~ 5270 Palm Valley Road, Ponte Vedra Beach, FL 32082 ~ 904-834-2938 ~ contact@healthyunow.org