1. Program of Facilitated Access to Recreation for People with Disabilities - Summer
Child name:

Age :

Age group corresponding to the level of incapacity:
New

Already have been register to the program in the past
Parent's name:

Phone number:

Address:

Town:
Saint-Lazare
Postal code:

Email address:

Is your child followed by a child interventionist (SRSOR, at school, social worker, etc...)?

Yes
No

            If yes, would you allow us to contact this person so we can learn more about your child
            (habits, behaviors, intervention plan, etc.)?

             Yes
             No

            Contact person:
            Name:
            

            Telephone:
            
Planned vacation dates



Which days do you planned need?
Monday       
Tuesday       
Wednesday       
Thursday       
Friday
NB: If your child is a new participant, we ask you to provide evidence (ex: doctor's note, specialist, etc.)
justifying your application to the program and the level of assistance required.


2. Description of the participant
Identification
Sex:
Will this person be matched?
Type of disability:
Hearing
Autisme

Intellectual
Physical

Mental health problem
Visual

Language or speech impairment
Autism spectrum disorder
Autonomy of the disabled person (answer all questions)
2.1 Communication
Langage utilisé :
speak        
gestural        
non-verbal        
a communication device (Bliss board or others)
2.2 Comprehension
The person makes himself understood
easily
with difficulty

Person understands
easily
with difficulty
2.3 Food
Person needs help to eat
Yes
No

Person needs help with drinking
Yes
No

Special diet
Yes
No
2.4 Clothing
The person needs to dress
Yes
No
   
2.5 Displacement
The person moves inside
Person moves outside
Person travels with other devices
2.6 Personal care
The person needs help with:

Other (explain):


   
2.7 Specific health problems
The person has health problems requiring a specific intervention by the guide
Yes
No

Nature of the problems:
severe allergy
epilepsy
cardiac problem
serious breathing problem
diabetes
Other (explain):


2.8 Behavioral issues
Person has behavioral problems
Yes
No

Nature of the troubles:
aggressiveness towards themselves
regular opposition
aggressiveness towards others
running away
occasional opposition
Other (explain):


2.9 Specific interventions of the guide
Interventions required by the guide:
orientation assistance
transfer aid (wheelchair)
stimulating participation
food aid
hygiene and health care
Other (explain):


Description of leisure activities
Description:
Start date:

YYYY-MM-DD
End date :

YYYY-MM-DD
Number of hours (minimum 40 hours maximum 240 hours):