Camp Consent form for Parents & Guardians

Please Select the Camp you wish to register your child in: *

Gr. 1/2 STEM & Reading Camp
Gr. 3/4 STEM & Reading Camp
Executive Functioning Camp

Child's First Name *

Child's Last Name *

Is your child a current client of The Speech Language Network? *

No, our child is new to SLN
Yes, our child is a client of SLN

Child's Date of Birth *

Child's Gender *

Male
Female
Gender X

Parent/Guardian 1 Full Name *

Parent/Guardian 1 email address *

Parent/Guardian 2 Full Name

Parent/Guardian 2 email address

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Secondary Phone

Add more siblings?

Sibling 1 Name

First

Last

Sibling 1 date of birth

Sibling 2 Name

First

Last

Sibling 2 date of birth

Sibling 3 Name

First

Last

Sibling 3 date of birth

Sibling 4 Name

First

Last

Sibling 4 date of birth

Speech-Language History of your child

Child's first language *

Other languages spoken in the home

Has your child had their hearing tested? *

Yes
No

Has your child ever had Speech Language Therapy? *

Yes
No

Location, services & length of therapy block.

Does your child enjoy or avoid the company of other children? *

Generally enjoys
Generally avoids

Does your child make eye contact with you when speaking or interacting with others? *

Please describe your concerns regarding your child's communication *

Birth / Medical History

Does your child have any health concerns you are aware of? *

Yes
No

Has your child had any serious illnesses or injuries? *

Yes
No

Has your child had any of the following? (Please check all that apply)

Please list any medications your child takes regularly

Please include: Prescription, over the counter, herbal, or natural products.

Birth / Development History

Were there any complications during the pregnancy or birth? *

Yes
No

Please describe the complications experienced during pregnancy or birth

Please provide the approximate age in months your child achieved the following developmental milestones

Sat alone

Babbles

Said first words

Put two words together

Spoke in short sentences

Grasped a crayon or pencil

Walked

Toilet trained

Does your child choke on food or liquids? *

Yes
No

Does your child currently put toys/objects in their mouth? *

Yes
No

Does your child brush their teeth and/or allow you to help them brush? *

Yes
No

Please provide any additional information you feel may benefit your child's therapy.

Please complete the following Camp Questionnaire to complete the Registration process

Does your child have a current diagnosis? If yes, please explain.

Behavioural (please check all that apply):

Unmotivated
Inattentive
Runs away, or wants to leave a situation when upset

Social-Language: Does your child have difficulty with any of the following:

What are your current concerns about your child’s performance at school? *

What are your current concerns about your child’s performance at home? *

Please list the classes or topics your child does the best in at school. *

Please list the classes or topics your child struggles the most with in school. *

What is your child’s favourite activities and hobbies? *

IF YOUR CHILD IS IN HIGH SCHOOL: Does your child have difficulty completing the following (check all that apply):

Turning in homework
Keeping backpack organized
Taking responsibility for self
Following a group plan

SLN Clinic Policies

SLN Clinic Policies can be found here. (Opens in a new tab).

Please review before completing & submitting this Form.

I have read and understand the policies of the Speech Language Network *

I agree

A copy of the policies will be sent to me for my records.

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