Beyond Akeela Application: Parent Questionnaire All fields required. Camper Name: Date of Birth: Camper's Current Grade in School: Parent Name: Parent Email: We are most likely interested in: First Session (6/25/18 - 7/14/18)Second Session (7/17/18 - 8/5/18) PARENT QUESTIONNAIRE We want to do our best to ensure that Beyond Akeela will be a great fit for your child. Therefore, please try to be as open and honest as possible as you answer these questions. Thank you! 1. Has your child ever attended camp? Has he/she spent the night (or longer) away from home? What were those experiences like for both you and your child? 2. What are his/her feelings about possibly attending Beyond Akeela this summer? 3. What would make this summer a success for your child? 4. What are your child's favorite activities at home, at school and in the community? 5.How well does your child interact with children close to his/her age? with easewith some challengewith difficulty Please Explain 6. What are the situations that are particularly challenging for him/her? What strategies have you found to be most effective? 7. How well does your child respond to requests from parents and teachers? (In other words, how well does he/she follow rules and expectations?) 8. Does your child have a history of verbal or physical aggression, destructive or self-injurious behavior? If so, please describe the circumstances, frequency and how long it's been since you have seen this behavior. What have been the most effective interventions? 9. As you can imagine, the Beyond Akeela experience includes a lot of transitions and changes in routine. How do you anticipate your child adjusting to this challenging environment? 10. What special services, if any, does your child receive at school (e.g. special education classroom, academic support, one-to-one aide, speech/language, social/emotional support)? 11. Many teenagers who struggle socially have also been diagnosed with a psychiatric disorder (e.g. anxiety, depression, mood or personality disorders). Please share with us any mental health needs that your child may have. 12. If your child sees a psychologist or mental health professional, how often do they meet? For how long has your child been working with this professional? In your opinion, how successful has the treatment been? 13. Does your child have any special health, hygiene, or dietary needs (including allergies)? 14. What medications/vitamins/supplements does your child take? (No need to give doses at this time.) 15. What is the MOST important thing you would like us to know about your child? Please type the code shown in the image. When you are finished, please hit the submit button only once. Thank you!