Frontier Travel Camp

Camper Application

This questionnaire is tailored toward gaining a better understanding of the potential traveler’s level of functioning in the areas of socialization, independence and over-all level of functioning. A more detailed medical evaluation will be required to be completed once your traveler has been accepted into our program.

Important: Please answer the following questions to the best of your ability with complete honesty with regard to your answers. Remember, this is a program for those with special needs. We need to know about strengths and weaknesses to better service your traveler’s needs. Therefore, answering questions honestly and fully will contribute to a successful summer experience for all.

This is an interactive form. Please complete all Steps 1-6 and submit when all fields are completed.

Subjects covered in the application are:

Indpendence
Psychological/Behavioral
Communication Skills
Socialization

Note: All information supplied in this application is strictly confidential and protected by Frontier Travel Camp, Inc. This information WILL NOT be shared to anyone outside of Frontier Travel Camp, Inc. staff, GUARANTEED!

You may download a PDF version of this online form.

Step 1: Traveler Information

Fields marked with * are required.
*Traveler's name:
*Date of Birth:
*Address 1:
*City:
*State:
*Zip:
*Home Telephone:
*Cell:
*Work Telephone:
*Mother's Name:
*Father's Name:
*Alternate Address:
*City:
*State:
*Zip:
*Upload traveler's image:
Other Phone Numbers:

Step 2: Independence

Step 3: Psychological/Behavioral

*Last clinical diagnosis by a practicing physician:
*Any other past diagnoses given:
*Hospitalizations due to non-medical reasons?
*If so, please explain with dates, duration, location and reason for hospitalization:
*Has the traveler had any history of depression?
*If so, please explain:
*Any history of suicidal ideation?
*If so, please explain how long ago, nature of attempt, etc.:
*Any history of physical, emotional and/or sexual abuse?
*If so, please explain in more detail:
*Would you consider the traveler sexually active?
*Does the traveler exhibit sexually provactive behavior?
*If so, please explain:
*Is there any reason to believe that the traveler would attempt to initiate sexual behavior with a roommate and/or traveleing companion?
*If so, please explain your thoughts:
*Does the traveler have temper tantrums?
*If so, please explain their duration, severity and frequency. Also include specific methods that help bring an end to these tantrums:
*Does the traveler have any history of fighting with peers?
*If so, please explain:
*Does the traveler exhibit agressive/confrontational behavior (i.e. bullying, antagonizing, name calling, etc.)?
*If so, please explain:
*Does the traveler smoke?
*Does the traveler use illegal substances/drugs?
*Is the traveler capable of taking care of all basic hygiene needs (i.e. bathing, washing, brushing, etc.)?
*If not, please explain specifically what assistance is needed:
*Please let us know anything related to this subject that we did not ask:

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*Where does the traveler live?
*Is the traveler currently employed?
*If so, please describe current position and job responsibilities:
*Please list any other work experience with duration of employment:
*How did these work experiences end?
*Does the traveler have a car?
*Does the traveler use public transportation independently?
*Has the traveler ever traveled without family?
*If so, please explain?
*Please share any additional information you would like us to know about this subject matter?

*Is the traveler capable of using words to let needs be known (i.e. ailments, expressions of feelings, dietary needs, etc.)?
*Please describe, in detail, any specific needs:
*If no, please describe anything that may help us to identify difficulties:
*Please supply an advice on what works for the traveler in dealing with the above issue:
*Is there any speech deficit?
*If so, please explain:
*Is the traveler capable of making purchases and/or ordering food unassisted?
*Please let us know anything that we did not ask that you feel is pertinent related to the area of communication:

*What kind of social outlets, if any, does the traveler have? Please include frequency and duration.
*Please describe any social difficulties that the traveler may have. Please be as specific as possible.
*Please list any behaviors that you would deem inappropriate which Frontier staff may need to be prepared for:
*Is there anything that you can tell us that may make the traveler more comfortable during the first few days of the tour (i.e. words that typically cheer-up the traveler, photos of family, televisions shows, music, etc.)?
*Please let us know anything that we did not cover in the area of socialization that you would like to elaborate on:

Frontier Travel Camp | Camper Application

SPECIAL NEEDS SUMMER TOURS & TRAVEL

High-Functioning young adults unite for unique summer experiences.

Camper Application

Subjects covered in the application are:

Step 1: Traveler Information

Step 2: Independence

Step 3: Psychological/Behavioral

Step 4: Communication Skills

Step 5: Socialization

Step 6: Submission

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Frontier Travel Camp | Camper Application

SPECIAL NEEDS SUMMER TOURS & TRAVEL

High-Functioning young adults unite for unique summer experiences.

Camper Application

Subjects covered in the application are:

Step 1: Traveler Information

Step 2: Independence

Step 3: Psychological/Behavioral

Step 4: Communication Skills

Step 5: Socialization

Step 6: Submission

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Dowload Our Forms...

Connect With Us!...

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