Summer Camp Application - The Diener School

Summer Camp 2024 Application

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General Information

Name of Camper(Required)

First Last

Nickname

Date of Birth(Required)

Age(Required)

School Information

Current School(Required)

Current Grade(Required)

Current School Address(Required)

Date of Attendance(Required)

School Phone #(Required)

Prior Schools: List all Schools/Date of Attendance/Phone Numbers

Contact Information

Name of Parents(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number

Parent 1 / Contact(Required)

First Last

Cell Phone (Parent 1)(Required)

Parent 1 / Contact Email(Required)

Parent 1 Occupation(Required)

Work Phone #

Parent 1 Employer

Parent 2 / Contact

First Last

Cell Phone (Parent 2)

Parent 2 / Contact Email

Occupation

Work Phone #

Employeer

If Secondary Residence or Contact/Guardian: Name/Contact Info

How were you referred to The Diener School Camp?(Required)

Child's Medical History

Were there any medical concerns at birth?(Required)

Have there been any hospitalizations since birth?(Required)

Is your child taking any medication? If so, name and dosage:

Name and phone of prescribing/supervising physician:

How long has your child been on this medication?

What other medications has your child taken in the past?

Does your child have any medical diagnosis, health, asthma, allergy issues?

Does your child have a formal or informal diagnosis of some type (Learning Disability, PDD, ADHD, etc) If yes please describe history of who performed testing, concluded diagnosis and approximate date of diagnosis and enclose report:

Therapeutic History

Please list the types of therapies your child is currently receiving, name and contact info of provider (tutoring, speech, sensory, etc.) How often? Please provide as much info as you can below.

Please list any other significant therapeutic resources your child previously received and whether you found them to be successful:

Attention Challenges

Does your child have difficulty focusing on schoolwork?

Does your child sustain attention appropriate to his/her peer group?

Rate your attentional concerns: (1 very concerned, 2 somewhat concerned, 3 no attentional concerns). Specify if necessary:

Social/Emotional

Please describe any social, emotional, and/or behavioral concerns that affect your child:

In school:

Outside of School:

Please describe your child’s social/emotional strengths:

Is your child anxious or depressed? Please describe:

Does your child take part in a social pragmatics group? If so with whom?

Does your child have difficulty making friends?

Does your child have trouble maintaining friendships?

How would you rate their self-esteem?

Does your child have meltdowns in school?

Does your child have meltdowns at home?

Does your child enjoy play-dates?

How do you think his/her social skills compare to their peers/siblings?

How does your child relate to adults?

How does your child relate to peers?

Does your child relate better to adults than with his own peers?

Sensory Checklist

1. Has your child ever been diagnosed or treated for sensory integration/sensory processing disorder?

2. Does your child have tactile defensiveness?

3. Does your child crave sensory input?

4. Does your child have any eating/feeding concerns?

5. Does your child crave movement?

6. Does your child shy away from loud noises, crowded rooms, etc.?

Please comment on your concerns regarding your child’s sensory issues:

Academic Questions

Does your child like school?

What type of teacher does your child best relate to?

What is your child’s area of academic strength?

What is your child greatest challenge in school?

General Questions/Comments

Please list some of your child’s favorite activities:

Things child dislikes:

Does your child have any special interests?

What is your child’s greatest strength?

What is your child’s greatest challenge?

What are your child’s favorite TV shows/movie/books?

Does he /she gets along with siblings?

Please make any other comments you feel would be helpful to us in knowing and working with your child.

Signature(Required)

Please Note: As we don’t have a recommended IQ score, our students need to demonstrate cognitive potential to benefit from our program. As we are here to provide the optimal educational experience for our students, we require that all questions must be answered with complete honesty and all of the above documents must be disclosed. The Diener School reserves the right to deny admission or remove for expulsion if there are any material disclosures that were not made.

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

Summer Camp 2024 Application

General Information

School Information

Contact Information

Child's Medical History

Therapeutic History

Attention Challenges

Social/Emotional

Sensory Checklist

Academic Questions

General Questions/Comments

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