Camp Crayon
Handwriting Intake
Physical, Occupational, Speech Therapy
Early Childhood Intervention & Audiology
Child’s First Name
Last Name
Date of Birth
Parent/Guardian First Name
Last Name
Email Address
Home Phone Number
Home Address
Work Phone Number
Age
Grade in Fall of 2016
Cell Phone Number
City
State
Zip Code
Does your child have any allergies, medical or physical conditions or precautions we should be aware of?
Please indicate which camp is preferred based on camp descriptions. CPT will place child once handwriting sample is reviewed.
Squiggly Scribblers
Classes will run for one week from 9am to 12pm — July 11th to July 15th
Squiggly Scribblers is designed for children who have had experience with numbers and letters in a
preschool environment, children who will be entering Kindergarten in the fall and/or struggled with
writing in Kindergarten and would benefit from a review of Kindergarten skills. This camp will utilize the
Letters & Numbers for Me workbook and will focus on teaching numbers, capitals and lower case letters.
Wiggly Writers
Classes will run for one week from 9am to 12pm — July 18th to July 22nd
Form of payment:
Check
Wiggly Writers is designed for children who are entering 1st or 2nd grade. This camp will utilize My
Printing Book workbook and will focus on review of upper case letters, correct use of lowercase letters in
words and sentences, spacing and letter alignment on different styles of lines
Loop de Loopers
Classes will run for one week from 9am to 12pm — July 25th to July 29th
Credit
Cash
Amount:
$________
Loop de Loopers is beneficial for children who are beginning to learn cursive or would benefit from a
remedial program. Camp will utilize the Cursive Handwriting workbook and will be adapted depending
on child’s cursive experience. Lessons will focus on learning upper case and lower case letters as well as
connecting them to form words and sentences.
Camp will be held in the Carolina Pediatric Therapy Hendersonville clinic at 510A Fleming St, Hendersonville, NC 28739.
Office: 828 670 8056 | Fax: 828 670 8057 | www.CarolinaPeds.com | 9 W Summit Avenue, Asheville, North Carolina 28803
Carolina Pediatric Therapy - Camp Crayon Handwriting Intake Page 2 of 7
Areas of concern with your child’s handwriting
(check all that apply)
Manuscript Letter Formation:
Lower Case
Upper Case
Both
Lower Case
Upper Case
Both
Doesn’t stay on the line
Inconsistent letter sizes
Use of capital letters
Difficulties writing sentences
Difficulties writing paragraphs
Use of punctuation
Spacing between letters
Spacing between words
Writes slow
Expresses pain
Cursive Letter Formation:
Overall Writing:
Fatigues easily
Pencil Pressure:
Pencil Grip:
Too Much
Too Little
Concerns
No concerns
Please attach a photo of child’s grasp if possible.
Additional Information
Does your child have a hand preference:
Left Handed
Does your child color and draw for fun?
Yes
Can your child read?
Yes
No
Does your child wear Glasses?
Yes
No
Right Handed
Mixed
Does your child enjoy physical activities?
Yes
No
Reading Level: (e.g. 2nd Grade; Pre-K) ________________________
No
If Yes:
Nearsighted
Farsighted
Describe your child’s preferred (or favorite) play activities: ________________________________________________________________
What strategies have your attempted to correct these handwriting concerns? _______________________________________________
What is your primary camp goal? ____________________________________________________________________________________
Services received in school (check all that apply)
Occupational Therapy
Physical Therapy
Speech Therapy
Special Education
Office: 828 670 8056 | Fax: 828 670 8057 | www.CarolinaPeds.com | 9 W Summit Avenue, Asheville, North Carolina 28803
Carolina Pediatric Therapy - Camp Crayon Handwriting Intake Page 3 of 7
Please have your child provide handwriting samples below.
After providing verbal instructions, please have your child complete independently.
Write your Name ( print or cursive )
Draw shapes here:
Color Shapes inside lines here:
Office: 828 670 8056 | Fax: 828 670 8057 | www.CarolinaPeds.com | 9 W Summit Avenue, Asheville, North Carolina 28803
Carolina Pediatric Therapy - Camp Crayon Handwriting Intake Page 4 of 7
Write your Numbers on the line below, from 1 through 10
Copy the Letters below ( print or cursive )
A
a
R
r
H
h
M
m
D
d
K
k
E
e
G
g
Office: 828 670 8056 | Fax: 828 670 8057 | www.CarolinaPeds.com | 9 W Summit Avenue, Asheville, North Carolina 28803
Carolina Pediatric Therapy - Camp Crayon Handwriting Intake Page 5 of 7
Draw a picture of a person here:
Copy the sentence below in cursive or print. ( Elementary students only )
The quick brown fox jumped over
the lazy dog.
Office: 828 670 8056 | Fax: 828 670 8057 | www.CarolinaPeds.com | 9 W Summit Avenue, Asheville, North Carolina 28803
Carolina Pediatric Therapy - Camp Crayon Handwriting Intake Page 6 of 7
General Camp Requirements:
1. Children must be entering Kindergarten through 5th grade in the fall
(some exceptions if approved by OT Staff ).
2. Must be able to participate and follow simple directions in a group setting (ratio of 1:4) for camp day
without direct one-to-one assistance.
3. Camps do not require a doctor’s order for participation since it is not considered therapy. Fees are not
billed to insurance.
4. Daily homework (no more than 10-15 minutes) may be assigned to progress the class appropriately
throughout the week.
5. Child will be screened for placement through the use of parent questionnaire/intake form with
handwriting sample.
6. Parent/caregiver will provide a daily snack and drink for child.
Signature:_________________________________________________________ Date:______________
Notice
Registration is incomplete until full payment is received with completed documentation of registration form, pages 1 through 7,
including photo release document.
Office: 828 670 8056 | Fax: 828 670 8057 | www.CarolinaPeds.com | 9 W Summit Avenue, Asheville, North Carolina 28803
Carolina Pediatric Therapy - Camp Crayon Handwriting Intake Page 7 of 7
Photograph, Film and/or Vocal Recording Release Form
Note: I authorize this release based on the following conditions:
These records become the property of Carolina Rehabilitation Specialists, Inc.
(DBA: Carolina Pediatric Therapy) or its representatives
This release is given without promise of compensation
9 W Summit Avenue
Asheville NC 28803
office: 828.670.8056
www.CarolinaPeds.com
This release is effective until terminated by a retraction in writing from the person
granting this authorization
The parent/legal guardian and the patient do release to Carolina Pediatric Therapy
any right, title and/or interest of any kind they may have in the records produced
A. Release to photograph, film or record vocally for publicity purposes
I hereby grant to Carolina Rehabilitation Specialists, Inc. (DBA: Carolina Pediatric Therapy) the right and authority to photograph,
film and/or record vocally:
Child’s First Name
Last Name
Age
These records may be used for promotional or publicity purposes and may be published in mass media publications, on the Carolina
Pediatric Therapy’s intranet or internet sites, or shown on television or movie presentations.
The patient’s and family’s name may be used. This release is effective until revoked in writing by the undersigned. Such revocation
shall only be effective to prevent any expanded future use of the records.
Signature (parent or legal guardian)
Witness (for authorization by phone)
Address
Phone Number
Date
B. Release to photograph, film or record vocally for scientific purposes
I hereby grant to Carolina Rehabilitation Specialists, Inc. (DBA: Carolina Pediatric Therapy) the right and authority to photograph,
film or record vocally:
Child’s First Name
Last Name
Age
These records may be used for purposes of study, research and teaching and may be published in scientific publications or on
the intranet or internet. The patient’s or family’s name may not be used. This release is effective until revoked in writing by the
undersigned. Such revocation shall only be effective to prevent any expanded future use of the records.
Signature (parent or legal guardian)
Witness (for authorization by phone)
Address
Phone Number
Date
Office: 828 670 8056 | Fax: 828 670 8057 | www.CarolinaPeds.com | 9 W Summit Avenue, Asheville, North Carolina 28803