Arc Broward

Camp Registration Request Form

Camp ABLE 2023

*Child's First Name:

*Child's Last Name:

*Gender: MaleFemale

*DOB:

*Age:

*Address:

*City:

*Zip Code:

*Parent/Guardian Name:

*Home Phone:

*Work Phone:

*Email:

*Child's Developmental Disability/Diagnoses:

Eligibility Requirements for Services

Applicants must meet all requirements below.

*Check all that apply:: Child is between the ages of 2 and 21 yearsChild is enrolled in a Broward Public School program (or McKay Scholarship Program) leading to HS diploma or equivalentChild resides in Broward County with natural or foster familyChild has a diagnosis of Developmental Disability (documentation of such will be required)Child is medically stable and does not require skilled nursing careChild can be transported in a non-handicap accessible 12-passenger van safelyChild will be in attendance on a regular basis for full term (8 weeks)Child has been denied enrollment or has been dis-enrolled from after-school/out-of-school programs due to his/her moderate-to-severe maladaptive behaviors

*Please list ALL current and prior after-school/out-of-school and summer programs your child has participated in during the past three years and reasons for dis-enrollment, if applicable:: Available characters remaining:

*Child displays behaviors that result in one or more of the following: : Harm or potential harm to child or othersInterference with child's adaptive skills and routines and/or learning opportunities Damage/harm to property or animals Disruption to environment/others Violation of acceptable social norms or rules Violation of law

Must meet one or more

*Describe specific behaviors from question above.: Available characters remaining:

*Are you interested in your child receiving OT, PT and/or Speech Therapy during camp through child's health insurance coverage, if authorized by insurance, or private payment?: YesNo

If you answered yes:

*Is your child currently receiving these therapies?: YesNo

*Does your child receive Medicaid?: YesNo

*If your child does not receive Medicaid, please list private health care provider:: Available characters remaining:



				Gore Family Memorial Foundation

PARTNERS