Email Child's full name Child's date of birth Parent/Guardian Name Address Emergency Telephone number Which group are you interested in? (Select both if you are available both weeks) Week 1: July 18-22, 2022; 10am-12pm (FULL - waitlist open) Week 2: July 25-29, 2022; 10am-12pm Both How will you be paying? Autism Funding (completed and approved RTP required) Cheque/Cash Indigenous grant Others Child Information Does your child have any medical conditions that we should be aware of? If yes, please describe. Will your child be taking any medication during group time? Yes No Other How does your child communicate? Vocal/Verbal Minimally verbal AAC Others Please email your child's IEP/home program to [email protected] Please email your child's IEP/home program to [email protected] I confirm that I have emailed my child's IEP What are your child's interests? What motivates him/her? Skills Assessment Please rate each area to the best of your ability. Note: we may offer you a place on our Social Caterpillars or Social Butterflies group pending this assessment. My child responds to hearing their own name. Always Sometimes Never My child can follow one-step instructions. Always Sometimes Never My child can follow multi-step instructions. Always Sometimes Never My child is able to sit and participate in a small group Always Sometimes Never Communication My child can request at least 10 different items using words, PECS, or AAC. Always Sometimes Never My child can ask for information using WH questions (e.g. what's your name, where is my juice?) Always Sometimes Never My child can politely request to stop an undesirable activity, or remove something aversive. Always Sometimes Never My child can give directions, instructions, or explanations as to how to do something or how to participate in an acitvity. Always Sometimes Never My child can request for others to attend to them (e.g. "Listen to me", "Here's what happened") Always Sometimes Never Behaviour My child is typically cooperative with adult instructions in a group setting Always Sometimes Never My child runs away or leaves a setting without permission. Always Sometimes Never My child hits or throws items at others. Always Sometimes Never My child hits themselves or hits a part of their body against an object. Always Sometimes Never My child can transition between activities with warnings without engaging in challenging behaviour (e.g. hitting others Always Sometimes Never Social Communication & Social Play My child shows an interest in others by approaching them or watching them. Always Sometimes Never My child engages in parallel play (e.g. sits near others and plays). Always Sometimes Never My child initiates interactions with peers (e.g. hand holding, pushing on a swing) Always Sometimes Never My child requests to their peers. Always Sometimes Never My child engages in sustained play with peers without adult prompts. Always Sometimes Never My child responds to requests from peers Always Sometimes Never My child asks peers WH questions (e.g. where do you live?) Always Sometimes Never My child can respond to WH questions asked by peers. Always Sometimes Never My child engages in pretend social play with peers (e.g. acting out videos) Always Sometimes Never My child can engage in conversation with others on a variety of topics. Always Sometimes Never Waivers and Releases I understand that the child to adult ratio during group time is 4:1 and I agree that my child does not engage in severe problem behaviour that poses a risk to themselves or others. Yes, I agree No, I do not agree I am aware that there are risks associated with the participation in Let's Play!, including the risk of injury, and I consent to my child’s participation in spite of such risks. I acknowledge that it is my responsibility to advise The Behaviour Change Clinic of any medical or other conditions which may affect my child’s participation in Let's Play! and have listed them above. I understand that I am responsible for immediately notifying staff/supervisor of any changes to the above information. In the event that my child requires medical attention, I consent to my child being transported to the nearest emergency centre, including by ambulance if necessary. I have read this form and understand and accept its terms. Yes, I agree No, I do not agree I consent to The Behaviour Change Clinic taking photos and/or videos of my child for advertising and/or training purposes. Yes, I agree No, I do not agree I understand that either myself or a designated contact will pick my child up from their group on time. Late pick ups are charged at a rate of $65/hr. Yes, I agree No, I do not agree I acknowledge that there are no refunds should my child be removed from the group and/or be unable to attend sessions. Yes, I agree No, I do not agree I understand that the group fee will be charged at once, and payment or RTP approval must be received at least 7 days prior to the start of the group. Yes, I agree No, I do not agree Send
