Child With Special Needs

Children With Special Needs, Additional Information Form

Thank you for your interest in our YMCA School Age Child Care and Camp Programs. We are committed to creating an environment where all children thrive, including children with special needs. A child with special needs is one whom it has been determined requires special attention and/or accommodation that other children in a group setting do not require. These determinations may be based on medical, physical, cognitive, or behavioral challenges that the child may face. Our program specializes in group child care and is an inclusive school age program that recognizes each child’s uniqueness. We are an independent program separate from the unified school district, do not have access to school resources or staff during our program hours, and operate under separate regulations. Our desire is to work with every family so that their child succeeds in our program. We will make reasonable accommodations in our program toward that goal, but we must note that there are some circumstances where we cannot effectively meet the needs of a child.

Child's Full Name

Child's Age

Grade

School Attending

Y Location Requested

Please summarize any special accommodation your child requires and/or challenges your child might face in our youth recreational program setting:

Does your child currently have any of the following? Mark all that apply.

Questions	Yes	No
One-on-One classroom support, or is enrolled in a special needs classroom	Yes	No
A dismissal or suspension from school or child care for aggressive behaviors	Yes	No
Medical condition that requires emergency medication	Yes	No
Food Allergy or significant dietary restriction	Yes	No
Additional equipment used by your child? If yes, please list below	Yes	No

Parent/Guardian Name

Phone

Preferred Method of Communication

Please provide any documentation regarding your child’s special needs that may help better equip us to make our determination. NOTE: This may include documents such as an IEP or similar analysis but is not required. We do NOT wish to receive any medical records.

Unlimited number of files can be uploaded to this field.
64 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

If your child has diabetes, asthma and or a seizure condition please indicate here so we can send the required emergency plan forms in advance:

Asthma

Diabetes

Seizures

Other…

Other

Please note that the YMCA does not employ medically trained staff. (i.e., nurses) Our staff are trained in Pediatric CPR/AED and First Aid only. We do not administer medication outside of that needed in emergency situations such as Epi Pens and asthma inhalers. We cannot assist in the administration of insulin, or any medication administered by injection.

Parent/Guardian Signature

Sign above

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