Child Info Request Form

Please fill out the questionnaire below, being as honest as possible. We use this information to determine how to best fully support your child in our Outdoor Leadership Program. It is important that we all start on the same page with honest and open communication. When pressing submit, give it 5-10 seconds to reload. Unless it says it didn't work, it was emailed to info@hikeandheal.com. Feel free to email with questions. Thank you!

Participant Questionnaire

* Indicates required field

Child's Name *

First

Last

Child 1 Age *

2nd Child's Name *

First

Last

Child 2 Age *

Did you participate in Camp Begin? *

Yes No

What are your hopes and dreams for enrolling your child in the Camp Beginnings program? *

Parent Name (main point of contact) *

First

Last

Parent Email *

Parent Cell # *

Does your child/children have an IEP at school? *

Yes No

Does your child/children receive OT, PT, Speech or related treatment outside of school? *

Yes No

What triggers cause your child/children to dysregulate? *

What are 1-3 hobbies / interests your child has? *

What is a leadership quality you'd like to see your child make gains in? In other words, what are your goals for participation in this program? *

What strategies work to prevent dysregulation? What helps your child? *

What strategies work for your child/children to come back to a calm state after dysregulation? *

What are 3-5 positive attributes about your child/children? *

Submit

Participant Questionnaire

CONNECT. INQUIRE. SUBSCRIBE.

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