JL Academy / Summer Camp Intake

Please select the program(s) you are interested in.*

JL Academy
Special Olympics Littles

Participant Information

Child's Name*

First Last

Date of Birth*

mm/dd/yyyy

Gender*

Female
Male

Diagnosis/Disability/Area of Delay*

Emergency Contact #1*

First Last Relationship to Child

Who does not have permission to pick your child up?*

First Last Relationship to Child

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alternate Phone

Email

Emergency Contact #2*

First Last Relationship to Child

Address*

Same as Emergency Contact #1

Street Address Address Line 2 City State ZIP Code

Phone*

Alternate Phone

Email

Please list any known allergies.*

Include food, medication, etc.

Does your child carry or need an epi-pen for an allergy?*

Yes
No

Does your child have Epilepsy/Seizures?*

Yes
No

Please list any medical conditions our staff should be aware of.*

Please list any medications your child is currently taking.*

Briefly describe any behavioral issues or special care for your child our staff should be aware of:*

Does your child have a history of, or currently have, any of the following?*

Check all that apply.

Please explain selections above.*

Task Supervision

Please indicate the level of supervision required for each task listed below.

Diaper*

Independent
Some Supervision
Constant Supervision
Physical Assist
Not Applicable

Toileting*

Independent
Some Supervision
Constant Supervision
Physical Assist
Not Applicable

Feeding*

Independent
Some Supervision
Constant Supervision
Physical Assist
Not Applicable

JL Academy

When would you like your child to participate in JL Academy?*

Enrollment is not complete until the upcoming month is paid in full. Invoice and payment must be received 5 days prior to upcoming month.

2-Day Option: Tuesday & Thursday | $40/week per child
3-Day Option: Tuesday-Friday (select days) | $60/week per child
5-Day Option: Monday-Friday | $100/week per child

Please list activities your child especially likes.

Please list activities your child especially dislikes.

Please list ways your child displays anger.

Please list security items.

Can Jacob's Ladder provide food (snacks) to your child?*

Yes
No

Please list foods that your child enjoys.*

Please list any food allergies/special dietary needs.*

Would you be willing to bring in a snack for your child so they can participate in Snack Time?*

Yes
No