Champions Application Form

First Name

Middle Name

Last Name

Nickname/Preferred Name

Date of Birth

Gender

Does your child have siblings?

No

Yes - they live in the same house fulltime

Yes - they do not live in the same house fulltime

Sibling 1 - Name

Sibling 1 - Age

Sibling 2 - Name

Sibling 2 - Age

Sibling 3 - Name

Sibling 3 - Age

Additional Siblings - Please list Name and Age for each

The child lives with -

Tip: Please select all applicable options

Is there any further detail you would like to add about living arrangements?

Mothers Name

Mothers Mobile

Mothers Email Address

Fathers Name

Fathers Mobile

Fathers Email Address

Guardians Name

Guardians Mobile

Guardians Email Address

Emergency Contact 1 - Name

Emergency Contact 1 - Relationship

Emergency Contact 1 - Mobile

Emergency Contact 2 - Name

Emergency Contact 2 - Relationship

Emergency Contact 2 - Mobile

Diagnosed Conditions: (e.g medical, educational, psychological, physical, etc):

Is your child (please select one)

Health Conditions (Please check all that apply)

Is your child given any prescription medications? (please detail medication and what each medication is for)

Does your child wear/use contact lenses or glasses?

Does your child wear a hearing aid?

Please describe other/additional health condition/s

Mobility Concerns

None

Uses Wheelchair

Requires Support

Other

Please describe your childs other/additional mobility concerns

Dietary Restrictions

Food Allergies

Other Allergies

Does your child require an epi-pen for allergies

Where is the epi-pen always kept? (e.g. Childs Bag front pocket)

Physical

Cognitive

Emotional

Social

Does your child attend school?

What Grade is your child in?

Does your child attend an Educational Support Centre? (please specify)

Does your child have additional support in the classroom?

Please specify what support your child has in the classroom.

Behaviours of concern

Please specify other behaviours of concern here:

How do you respond to behaviours of concern?

Please specify any other responses you use here:

Reinforcement and Reward System

Please specify other reinforcements and rewards you use with your child:

Does your child have any assistive devices?

Please add any other assistive devices your child uses here:

Toileting Skill Level (Please check all that apply)

Independent/Toilet Trained

Wears Nappy/Pull-ups

Requires Complete Assistance during bathroom use

Requires Partial Assistance during bathroom use

Specific Parental Instructions/comments in regard to toileting

Childs Eating Skill Level (Please check all that apply)

Independent/Feeds Self

Requires Complete assistance during eating

Requires Partial assistance during eating

Has feeding tube/Nothing by mouth

When your child gets excited, what does he/she do?

When your child gets anxious, what does he/she do?

When your child gets frustrated, what does he/she do?

What is your child afraid of?

What calms your child? (e.g. during a tantrum, when they are afraid or anxious)

Your childs likes: (Characters, songs, books, food, activities, games etc)

Your childs dislikes: (Characters, songs, books, food, activities, games etc)

Please provide any additional information that would assist us in caring for your child:

CHAMPIONS - Initial Registration

Child's Details

1. Family Information

Emergency Information

2. Medical & Health Information

3. Dietary Restrictions & Allergies

4. Support

Educational Information

Behaviour Information

Other Support