Child’s name: ___________________ DOB: ____________ Age: ______

Address: ______________________________________________________

Parent name: _______________________________ Phone: ________________

Name of parent support person or friend helping with this application further explaination

________________________________________________________________

Child’s interests further explaination:

___________________________________________

Reason for request further explaination:

________________________________________________________________

Activity requested: _________________________________________________

NAME OF ORGANIZATION: ___________________________________________

Organization Phone: ___________ Organization bookkeeper’s name: _______

Organization’s address:

Visit to the organization

Parent has discussed the activity requested with teacher/coach/instructor

“care coach” further explaination:

____________________________________________________

Name of teacher/coach/instructor/ “care coach” who will be doing the activity with the child: ____________________________________________________________

Parent/child Interview visit at the facility further explaination:

_______________________

Child’s response to visit: ___________________________________________

The activity instructor/coach/teacher agreed to provide more attention to

help the child feel safe and secure so he or she is free to focus on the

activity and enjoy the experience. ___________________________________

Cost ______

Parent, or other person providing some contribution to the match:

_____________________________

Special instructions to the recreational/activity organizations about the cost and payment: ________________________________

We ask the organization (activity provider) to help us track the child’s attendance and progress and provide feedback to Able-differently.

Organization contact person: ______________________

Please complete the following behavioral scales before

further explaination

the activity begins complete the following:

Daily Child Strength Scale to be done with your child – you may help him or her.

Past Week’s Quality of Family Life to be completed by parent

Pediatric Symptom Checklist (English and Spanish versions are available) to be completed by parent, coach/instructor and schoolteacher, if possible

And complete ratings to help reflect on your child and family before the activity begins:

(These checklists and ratings will be repeated again after all days of activity or classes are done).

Disclaimer: ABLE-differently will not assume responsibility and will be immune for any potential liable claims for imputed wrongful actions or bodily or emotional injury of said minor potentially incurred by participation in stated activity.

Parent Signature: ______________________ Date: _____________

Amount of scholarship money awarded by Able-differently $_____

________________________________________________________________

Beginning Date for the activity: _________

During the time of the activity take photographs of the child during the class and with the instructor to help keep the experience in your child’s and your memory.further explaination

The coach or parent support person can help you take these photographs, perhaps with your phone if you have such a technology.