Student’s Name: _______________________________

 

E-mail Address: ________________________________

 

Birthdate: _____________    Age: _______   Sex:  M   F

                 

Name of School: _______________________________

 

Parent’s names:

_____________________________________________________

_____________________________________________________

                 

Home Phone: ____________­­­­­______________  

Cell Phone: ____________________________

Work Phone: ___________________________  

Emergency Phone:_____________________

 

Address ____________________________________________

 

City __________________________________

 

State: ______________________ Zip: _________________

 

Email: ________________________________________

BHMC is a total communication camp and will strive to meet the needs of each child’s unique communication and social skills.  To help us meet these needs please respond to the following:

 

 Method of Communication Preferred:

(BHMC will try to provide complete access to communication.  Students will be exposed to a variety of communication methods) ________________________________________________________________________________________________________

________________________________________________________________________________________________________

 

 

Specific Needs or Issues:

________________________________________________________________________________________________________

____________________________________________________________________________________________

 

 

Specific Likes or Dislikes:

(BHMC will expose individuals to new experiences. Camp staff will work hard to ensure positive reactions to these new experiences.) ________________________________________________________________________________________________________

_____________________________________________________