2021 Camp FRIEND Interest Form

Please fill out this Camp FRIEND interest form.
Our Camp Director and Committee will then review the applications and then email acceptance letters to those accepted.
Camp FRIEND is for individuals with an autism spectrum diagnosis living in Mahoning, Trumbull or Columbiana counties only. It is a recreational camp not therapeutic. We serve individuals ages 4 through 19 years old

* All Fields Required

Please specify what week(s) you would like your child to attend:
July 19-23
August 16-20

Campers Name:
Age:
County:
Street Address:
City:
State:
Zip:
Primary Parent/Guardian Name:
Cell Phone:
Email:

Camper Information
Allergies:
Diagnosis (or Diagnoses):
Medication:
Does the medication need administered during camp hours?
Food Restrictions or Allergies:

School Information
School your child attends (Name & city/town):
Type of class (i.e. resource, self-contained, etc.):
Student/teacher ratio:
Does your child have a one-to-one aide?

Preference and Reinforcement
Favorite Items/Activities:
Dislikes:
What are some calming techniques that work for your child?:

Describe your child's behavior when he/she is having difficulty (not getting his/her way):


Characteristics
How does your child communicate? (verbal, AAC device, picture cards, sign):
Is the child in pull-ups or if potty trained do they request to use the restroom or what is needed for them to be successful?

How does your child react to stress? Transitions?

How does your child display anger? Are they destructive?

Does your child express his/her needs? If so, briefly explain how:

Does your child engage in aggressive or self-injurious behaviors?
If so how do you respond to these behaviors to keep them safe?