THE LANGUAGE AND BEHAVIOR CENTER

TLBC Summer Social Camp

Make a memorable experience at our Summer Social Skills Camp, where you can meet new friends and practice a variety of social skills!

TLBC Summer Social Camp Interest Form

Thank you for your interest in TLBC's 2024 Summer Social Camp! Please complete this form to the best of your ability. Once received, TLBC's Center Based Services Coordinator will reach out to you for the next steps.

*Please Note: This form is solely to express interest in TLBC Summer Social Camp and does not guarantee a spot in the summer camp.

Camp runs from August 12 - 23rd

Camp days start at 9:00AM and end at 12:00PM

Your Name

Relationship to Child

Email Address

Phone Number

Address

How did you hear about our summer camp?

Child's Name

Child's Date of Birth

Child's diagnosis (Autism, ADHD, etc.)

Current Medications (and times of administering)

Is your child toilet trained? (i.e., wears underwear and initiates)?

Yes

Other

Why are you interested in having your child join TLBC's Summer Social Camp?

Please describe your child's current communication skills (ex. gestures, 1-2 words, full sentences, etc.)

Please describe your child's current play skills (ex. repetitive, rigid, functional, imaginative, etc.)

How does your child interact with their peers? (ex. stays away, approaches other, plays near kids, takes turns, etc.)

What are your goals for your child?

We would love to personalize your child's experience! What are some of their current interests?

Other Information: Please include any information you think we should know about your child that we haven't asked you about in this intake form.

Initials

Today's Date

Thanks for submitting! Our Center-Based Coordinator will be in touch shortly!