L.E.A.P 2024 Application

L.E.A.P 2023 Application
Camper’s Name
Camper's Name
First
Last
Sex
Radio Buttons
Parent/Guardian Name:
Parent/Guardian Name:
First
Last

Please review the camp dates below.

I am applying to:

Sessions run Monday-Friday 9:00 am-3:00pm. Before/After care is available for parents who need it. The hours for summer before care are from 8:00-9:00 a.m. (flat fee of $20/day) and from 3:00-5:00 pm ($20/hour). Late pickup fee: $1/minute for every minute after 3:05 p.m.

CAMP FEES FOR EACH SESSION: Regular Registration: $350.00 for two weeks

FEES FOR EACH SESSION: $350.00 to be paid in full before the 1st day of camp. Early Registration: ends May 31st, 2023 – (Registration Fee $100). From June 1st, 2023 and onward – (Registration Fee $150) All registration fees are non-refundable.

Registration fees secure your child’s placement.

All payments for all registered sessions are to be paid in full prior to start of the session.

Emergency Contact Information

Please include two additional contacts who may be notified in the event of an emergency and we are unable to reach primary contact.

Emergency Contact #1
Emergency Contact #1
First
Last
Emergency Contact #2
Emergency Contact #2
First
Last

Medical Information

*I agree to pay any and all charges which may become necessary during emergency treatment in the event L.E.A.P Camp Staff is unable to locate parent/guardian.

Parent Questionnaire

1. My child prefers to do things with others than on his/her own
2. Says at least 100 words
3. Gets upset when he/she can’t pursue interests
4. Does not get upset if daily routine is disturbed
5. Enjoys doing things spontaneously
6. Has a diagnosis of schizophrenia, ADHD, bipolar, or similar disorders?


7. Communicates with gestures
8. Uses echolalia, immediate or delayed
9. Takes a literal interpretation of comments
10. Uses eye contact in a conversation
11. Has routines or rituals that must be completed
12. Has poor motor coordination
13. Is good at turn-taking in conversation
14. Has unusual or repetitive movements
15. Joins in playing games with others easily
16. Has hearing or visual difficulties
17. Is toilet trained during the day
18. Seeks medical help when needed (i.e. recognizes own feelings of pain, discomfort, illness)
19. Responds appropriately to reasonable changes in routine.
20. Is impulsive.
21. Has temper tantrums in school/camp setting
22. Is physically aggressive towards self/others
23. Wanders or runs away at times

Photo and Video Release

I hereby authorize Play–Place Autism & Special Needs Center to use:

My child’s image may be used for: Any and all forms and media including without limitation use on the World Wide Web now or hereafter, and for any purpose whatever including without limitation illustration promotion, publicity, art, education, advertising, trade, fundraising, and if appropriate, to use my name, pertinent education and/or biographical facts.

Limitations

We accept Michigan MEDICAID, Oakland Family Services, EASTERSEALS (Oakland) & CHILDREN'S WAIVER families for RESPITE. NO Wait List! YOU DESERVE A BREAK.

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