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New Student: Summer Program Application
2017
Name: ______________________________________________
Nickname:_________________________
Date: _______________________________
DOB:_________________
Age as of 6-1-17________________
Address:_______________________________________________________________________________________
City, State, Zip Code _____________________________________________________________________________
Child’s Home School District _______________________________________________________________________
Grade Completed _____________
Attending (Check all the apply): ____ ESY ____Pottery Camp ____ESY2
Primary Phone Number:___________________________________________________________________________
Child’s Gender:__________________________________________________________________________________
Father’s Name:__________________________________________________________________________________
Father’s Address:________________________________________________________________________________
City, State, Zip Code _____________________________________________________________________________
Father’s Home Phone:____________________________________________________________________________
Father’s Email Address:___________________________________________________________________________
Father’s Cell Phone:______________________________________________________________________________
Father’s Occupation/place of employment:_____________________________________________________________
Mother’s Name:__________________________________________________________________________________
Mother’s Address:________________________________________________________________________________
City, State, Zip Code:______________________________________________________________________________
Mother’s Home phone:_____________________________________________________________________________
Mother’s email Address:____________________________________________________________________________
Mother’s cell phone:_______________________________________________________________________________
Mother’s occupation/place of employment:______________________________________________________________
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Please list names and ages of all those living in the home _________________________________________________
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Has your child ever attended a preschool program or daycare at another facility?______________________________
If so, where? _____________________________________________________________________________________
_______________________________________________________________________________________________
Please list any medical or educational challenges your child may have been diagnosed with and who gave the
diagnoses._______________________________________________________________________________________
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Does your child have other special medical considerations we need to be aware of?_____________________________
_______________________________________________________________________________________________
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Please list any medication that your child takes on a daily basis:____________________________________________
_______________________________________________________________________________________________
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Child’s physician_________________________________________________________________________________
Phone Number__________________________________________________________________________________
Does your child have any allergies? If so, please list items.________________________________________________
_______________________________________________________________________________________________
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Is your child potty trained? Please Circle. Yes
Needs Minimal Assistance
Needs Assistance
No
Is your child on a special diet:__________________________________________________________________
If so, please describe______________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Name______________________________________________ Date___________________________
DOB___________________________________ Gender ____________________________________
How does your child communicate: Please circle all that apply:
Verbally
2-3 word phrases
Sign language PECS
Communication Device
Non-communicative
Written
Pointing
Other_____________________
Does your child presently see a speech therapist?______________________________________
Name of Speech Therapist ________________________________________________________
What is your child’s primary area of need in the area of communication? __________________
_____________________________________________________________________________
Please check the following that apply:
_____ My child has articulation errors
_____ My child understands what I say and often responds
_____ My child often does not seem to understand what others say
_____ My child speaks but his/her language is often babbling or meaningless
_____ My child tries to communicate wants and needs through verbal communication
_____ My child often seems frustrated because he/she is not understood
_____ My child has difficulty initiating conversation
_____ My child uses a picture communication system
_____ My child uses sign language
_____ My child has an augmentative communication device. Which one?______________
_____ My Child’s language consists mostly of scripts from movies and books
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Can you estimate the amount of works your child uses regularly?
_____ Less than ten
_____ Between ten and thirty
_____ Between thirty and fifty
_____ Between fifty and one hundred
_____ Hundreds of words
What would be your number one goal in language and communication for your child?
_______________________________________________________________________
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Name______________________________________________ Date___________________________
Toileting
Child Is fully toilet-trained and goes without reminders and without help
___________
Child is fully toilet-trained but goes on a schedule and without help
________________
Child is fully toilet-trained but goes on a schedule and does need help
_________________
Child is trained for urine but not bowel movements
________________
Eating
Child is able to drink from the following:
_____ straw
_____ sippy cup
_____ small cup with no lid
Which does your child drink from most often? ________________________
Is your child independent with eating utensils? _________________
Does your child chew and swallow thoroughly? _________________
Can your child self feed with a spoon or fork? __________________
Is your child limited in what he/she chooses to eat? If so, describe ________________
______________________________________________________________________
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Other Self-Help Skills
Please write yes or no for the following: Can your child:
_____
Put on shoes
_____ Take Off Shoes
_____ Put on socks
_____ Take of socks
_____ Pull down pants
_____ Pull up pants
_____ Pull down underwear
_____ Pull up underwear
_____ Put on shirt
_____ Take off shirt
_____ Brush teeth with limited help
_____ Wash hands
_____ Brush hair
Please use the space before to share any self-help concerns you have for your child, or any extra areas in
which they may need help.
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Child’s Name _____________________________________ Date ______________________________
DOB____________________________________ Gender _____________________________________
Please check the following that apply:
_____ My child becomes upset if he spills something on his clothes
_____ My child is sensitive to strong smells
_____ My child is alarmed by loud noises and loud spaces
_____ My child is distracted or becomes agitated with some types of lights
_____ My child is very picky about the fabrics he/she will wear or tags in clothes
_____ My child is uncomfortable with certain textures. Please list on back
_____ My child often falls off of his seat
_____ My child enjoys using a weighted blanket
_____ My child likes to hold small objects in his/her hand
_____ My child does not like to be touched
_____ My child will not walk on the grass barefooted
_____ My child does not like to have haircuts or get hair washed
_____ My child likes to spin or watch things spin
_____ My child likes to swing
_____ My child likes to jump on the trampoline
Please list things that make your child uncomfortable and things that make your child feel calm:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Does your child see an occupational therapist ______ Name ____________________________
Student Name ____________________________________ Date ___________________________________
Reinforcer Questionnaire
Student Name: ______________________________________ DOB ______________________
Person Completing: ___________________________ Relationship: ________________________
Date Completed: ___________________ Teacher’s Name _______________________________
Dear Parent,
This questionnaire is to determine the items/experiences that give your child joy or satisfaction. In
addition, we would also like to know about items that create a negative response. It is our goal to
use the listed desired items to increase targeted behaviors and promote learning.
We have provided a check list of reinforcers for you to choose from on the following pages. In the
space below and on the following page please tell us additional reinforces that work for your child.
Additional reinforcers for my : (Positive or Negative)
Student Name __________________________________________ Date ________________________________
Reinforcer Checklist
Edible Reinforcers:
Yes
No
Candy: 1. M&M’s
2. Jelly Beans
3. Licorice
4. Candy Canes
5. Gum
6. Smarties
7. Lollipops
8. Candy Kisses
9. Chocolate
10.________
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Cereals:11. Cherrios
12. Fruit Loops
13. Trix
14. ____
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Fruit
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Liquids: 20. Milk
21. Ch. Milk
22. Juice
23. Soda Pop
24. Lemonade
25. ______
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Frozen: 26. Popsicle
27. Ice Cream
28. ______
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Soft:
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15. Raisins
16. Apples
17. Oranges
18. Bananas
19. ____
29: Pudding
30. Jell-O
31. Yogurt
32. Marshmallows
33. Cheese
34. Cottage Cheese
35. Peanut Butter
36. Jam/Jelly
37. ____
Others: 38. Cake
39. Cupcakes
40. Doughnuts
41. Crackers
42. Frosting
43. Pretzels
44. Corn Chips
45. Cheez Balls
46. Doritos
47. Cookes
48. Popcorn
49. Vegetables
50. _______
Material Reinforcers
1. Stop watch
2. Hand Cream
3. Bubbles
4. Combs
5. Stickers
6. Play Dough
7. Perfume
8. Toy Instruments
9. Puzzles
10. Beads
11. Stamps
12. Masks
13. Crayons
14. Fans
15. Balloons
16. Bean Bags
17. Hats
18. Mirrors
20. Coloring Books
21. Whistles
22. Blocks
23. Books
24. Paints
25. ____
Yes
No
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Student Name:_________________________________________ Date: _________________________________
Activity Reinforcers:
YES
1. Rocking
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2. Brushing Hair
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3. Clapping Hands
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4. Airplane Rides
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5. Drawing Pictures ____
6. Run Outside
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7. Hide and Seek
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8. Piggyback Rides
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9. Chase
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10. Peek-A-Boo
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11. Sing Songs
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12. Sprinkle Glitter
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13. Tickles
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14. Water Play
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15. Puppets
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16. Sand Play
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17. Trampoline
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18. Dancing
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19. Bring Toy from Home____
20. Turn Lights On/Off____
21. Pour Liquids Back/Forth____
22. Video tapes
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23. Stories
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24. Being the Teacher ____
25. Talking on Phone ____
26. Drink in Office
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27. Drawing
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28. Draw on Chalkboard____
29. Lunch/Snack Helper____
30. Field Trips
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31. Twirling in Air
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32. Blankets over Head____
33. Taking Pictures
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34. Going to Trash
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35. Roll Down Hill
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36. Teacher’s Helper ____
37. Making Pictures:
with Popcorn ____
with Noodles ____
with String
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38. Running Errands ____
39. Playing in Boxes ____
40. Dressing Up
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41. Climbing
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42. Stim Time
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43. Rocking in Boat
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44. Cutting Pictures ____
45. Playing with Glue ____
46. Treasure Hunt
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NO
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YES
47. Looking at Pictures____
48. Basketball
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49. Finger Paint
with Pudding ____
with Whipped Cream____
with Soap
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with Paint
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50. Racing
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51. Wagon Rides
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52. Thrown in Air
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53. Make Copies
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54. Water Plants
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55. Going for Walks ____
56. Making Treats
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57. Icing Cupcakes
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58. Making Popcorn ____
59. Playing Ball
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60. Playing with Tools ____
61. Birthday Parties ____
62. Playing with Zippers____
63. Blowing Bubbles ____
64. Swimming
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65. Listen to Music
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66. Play with Typewriter____
67. Stringing Beads
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68. Turning Water On/Off____
69. Smelling Spices
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70. Fishing Game
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71. Dart Board
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72. Grab Bag
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73. Surprise Box
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74. Spinner
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75. ____
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Social Reinforcers:
1. Hugs
2. Shaking Hands
3. Kisses
4. Tickling
5. Winking
6. Give Me Five
7. Rubbing Noses
8. Smiling
9. Whistling
10. Patting
11. Praising
12. Back Scratch/Rub
13. Praise
14. ____
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Student Name____________________________________________Date __________________________________
Most and Least Popular Reinforcers as Ranked Using the Reinforcer Checklist
Category
MOST
LEAST
Edible Reinforcers
Crackers
Cookies
Marshmallows
Cupcakes
Ice Cream
Juice
Soda Pop
Doughnuts
Popcorn
Corn Chips
Licorice
Raisins
Cheerios
Apples
Jell-O
Raw Vegetables
Candy Canes
Oranges
Milk
Frosting
Material Reinforcers
Toy Instruments
Bubbles
Balloons
Mirrors
Blocks
Paper and Crayons
Play-Doh
Hats
Coloring Books
Beads
Social Reinforcers
Tickling
Smiling
Praising
Hugging
Patting
Blowing
Pinching Cheeks
Twitching Noses
Back Scratching
Whistling
Activity Reinforcers
Going for Walks
Watching Popcorn Pop
Rocking
Musical instruments
Time alone
Water play
Clapping Hands
Playing in front of mirror
Field trips
Running Outside
Drinking out of pop bottles
Climbing
Wagon Rides
Flushing Toilet
Having Mom leave class
Cutting pictures from magazines
Making pictures with popcorn, noodles, or string
Stringing Beads
Taping and Tearing paper
Playing with Paper
Crayons
Drawing pictures
Stories in Teacher’s lap
Finger painting with paint, pudding, or whipping
cream
The Bridge of Georgia
Emergency Contact and Medical Information for a Child
Student Name___________________________________________________ DOB ___________
□ Male □ Female
Address________________________________ City/ST___________________ Zip________ Phone_______________
EMERGENCY CONTACTS
Emergency calls will be made in order listed below. Only contacts listed on
this emergency form will be permitted to pick your child up from school.
Parent/Guardian Contact Information
Parent/Guardian:_________________________________________________
Check Preferred
□ Home □ Cell □ Work □ Email
Address:____________________________________________________________
Preferred #/email____________________________
City:__________________________________ State______________ Zip ________
Last 4 Digits SS#____________________________
Relationship:
□
Mother
□
Father
□
Legal Guardian
Parent/Guardian:_________________________________________________
Check Preferred
□ Home □ Cell □ Work □ Email
Address:____________________________________________________________
Preferred #/email____________________________
City:__________________________________ State______________ Zip ________
Last 4 Digits SS#____________________________
Relationship:
□
Mother
□
Father
□
Legal Guardian
Please list at least two people we may call if the parent(s) or guardian(s) cannot be reached in the event of an emergency.
These people also have your permission to pick your child up from school during the school day.
Preferred Contact
1
2
3
4
Name
Relationship
Home#
Cell#
Last 4 SS#
The Following people do NOT have permission to pick my chick up from The Bridge (Please provide Legal Documents
____________________________________________________________________________________________
Medical Information
Student’s Weight___________________
Physician’s Name______________________________ Phone# __________________________Hospital Preference_________________________________
Insurance Provide:_____________________________ Policy#___________________________ Name on Policy ___________________________________
PLEASE LIST ALL MEDICATIONS YOUR CHILD TAKES ON A REGULAR BASIS:
Name of Medication
Dose
Doctor
Phone#
If medications will be given at school please fill out the Medical Authorization Form
GENERAL HEALTH: (Please circle any that may pertain to your child)
Asthma Migraines ADD/ADHD Reflux or Indigestion Hypoglycemia Epilepsy Bone/Joint Problems Heart Conditions Head Injury
Diabetes Bladder/Kidney Problems Seizures Nose Bleeds Other: _________________________________________
Allergies to Medications: No____ Yes _____ Lists: _______________________________________________
Allergies to Food: No_____ Yes_____ Lists:_____________________________________________________
Allergies to insect bites/bee stings: No_____ Yes____ Lists:_______________________________________Other Allergies ________________________
Parent/Guardian Signature ________________________________________________ Date __________________________________________________
I authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or
prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the
event that neither parent/guardian can be reached in the case of an emergency.
The Bridge of Georgia --- Summer Programs
I, _____________________________________________, parent/legal guardian(s) of ___________________
do hereby agree to the following. Please initial beside each statement.
_____ 1. I agree to abide by all the rules and regulations established by The Bridge of Georgia.
_____ 2. I understand that a non-refundable deposit is due at registration. Deposit will be made by placing payment in
the payment envelope at the front desk. The person making payment should complete the envelope including
what the payment should be applied to (ESY1, Pottery or ESY2 deposit)
_____ 3. I agree that the balance for ESY1 is due 5-26-17, Pottery Camp is due 5-20-17 and ESY2 is due 7-11-17.
Payment should be made by placing payment in the payment envelope at the front desk and placing in
payment mailbox. Please include on the envelope exactly what the payment should be applied to (i.e. balance
due for ESY1)
_____ 4. I agree to be responsible in providing The Bridge with the most current custody or guardianship and any vital
health information that could be necessary in the proper care and safety of the student.
_____ 5. I agree that when concerns arise we will first take those to the person directly responsible for working with
the child. If our concerns are not addressed adequately, we will then take our concerns to the supervisor
responsible for that employee.
_____ 6. I understand that no allowance or reduction will be made for late arrival or early departure of student. No
refunds will be given if unable to attend.
_____ 7. Students who are not picked up by the end of carpool (10 mins after dismissal) will be charged at a rate of
one dollar per minute until time parents arrive.
_____ 8. I give my child permission to participate in all outlined activities, including outdoor play, and understand that
injuries could occur.
_____ 9. Permission is given for The Bridge of Georgia to sue in promoting summer programs digital, photographic,
video, and audio images or likenesses of student, work or art created by the student during the summer
program.
Notice of Exemption from Licensure
_____ I understand that The Bridge of Georgia School has gained exemption from licensure from Bright from the Start.
I understand that any complaint I have will need to be brought to the administration of The Bridge of Georgia
School to be addressed by them or taken before the Board of Directors.
I accept and agree to abide by the above guidelines. Any concerns should be noted here
_____________________________________________________________________________
Printed Name of Parent/Guardian__________________________________________________
Parent/Guardian Signature________________________________________Date____________