Camper application

Traveler's name:

Date of Birth:

Address:

City:

State:

Zip:

Phone Number(s):

Upload traveler's image:

Where does the traveler live?

Please Select an OptionWith parentsIn a school settingIn a group homeIndependently

Is the traveler currently employed?

Yes


No

Does the traveler have a car?

Yes


No

Does the traveler use public transportation independently?

Yes


No

Has the traveler ever traveled without family?

Yes


No

Please share any additional information you would like us to know about this subject matter?

Last clinical diagnosis by a practicing physician:

Any other past diagnoses given:

Hospitalizations due to non-medical reasons?

Yes


No

Has the traveler had any history of depression?

Yes


No

Any history of suicidal ideation?

Yes


No

Any history of physical, emotional and/or sexual abuse?

Yes


No

Would you consider the traveler sexually active?

Yes


No

Does the traveler exhibit sexually provactive behavior?

Yes


No

Is there any reason to believe that the traveler would attempt to initiate sexual behavior with a roommate and/or traveling companion?

Yes


No

Does the traveler have temper tantrums?

Yes


No

Does the traveler have any history of fighting with peers?

Yes


No

Does the traveler exhibit aggressive/confrontational behavior (i.e. bullying, antagonizing, name calling, etc.)?

Yes


No

Does the traveler smoke?

Yes


No

Does the traveler use illegal substances/drugs?

Yes


No

Is the traveler capable of taking care of all basic hygiene needs (i.e. bathing, washing, brushing, etc.)?

Yes


No

Please let us know anything related to this subject that we did not ask:

Is the traveler capable of using words to let needs be known (i.e. ailments, expressions of feelings, dietary needs, etc.)?

Yes


No

Is there any speech deficit?

Yes


No

Is the traveler capable of making purchases and/or ordering food unassisted?

Yes


No

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:

Your Name:

Your Email: