Social Recreation Interest Form - East

This program is made possible through the support of Trillium Health Resources. The program involves group activities and sessions as well as one-on-one supports (when needed) in a day camp environment with occasional community outings.

Program Participant Info

Child name*

First Middle Last

Date of Birth*

Primary Address*

Street Address Address Line 2 City State

Zip Code*

County*

Mailing Address (if different from primary)

Street Address Address Line 2 City State

Zip Code

County

Please share your ethnicity:*

Asian
Black/African American
Caucasian/White
Hispanic or Latino
Native American or Other Indigenous
Native Hawaiian or Pacific Islander
Two or More Races
Other/Unknown
Prefer not to answer

Preferred Language in Your Home

English
Spanish
Other

Contact Information

Primary Contact*

Prefix First Last

Select your role*

Parent
Legal Guardian
Self

Are you the legal guardian?*

Yes
No
I'm an adult/Own legal guardian

Email address - please list email which is checked regularly*

Phone - preferred*

Phone - secondary

Secondary Contact

Prefix First Last

Are you the legal guardian?

Yes
No

Email

Phone - preferred

Service Eligibility

Which service(s) are you interested in? (select all that apply)*

Select All
Summer programming (M-F, 9am-5pm- dates provided below)
Afterschool programming (M-F, 2:30-6:30pm- dates provided below)
Adult programming
Weekend/evening respite events

Location you are interested in:*

Greenville/Winterville: 4882 Reedy Branch Road, Winterville, NC (Autism diagnosis only)
Newport/Carteret area program: 113 Roberts Road, Newport, NC (Autism or IDD diagnosis)
Wilmington area: 705 S. Kerr Avenue, Wilmington, NC (Autism diagnosis only)

Diagnosis*

Please upload a psychological assessment/evaluation as evidence of the identified diagnosis. This is required for admission to the program.  All PHI (personal health information) will be protected as dictated by the HIPAA.

Drop files here or

Max. file size: 300 MB.

Please answer the folllowing:*

I have uploaded a copy of the psychological assessment
I will provide a copy of the psychological assessment if the applicant is deemed eligible for admission to the program

Does your applicant receive Medicaid?*

Yes
No

Does your child receive other services through Trillium Health Resources, the Autism Society of NC, or another provider?*

Yes
No

Select the service your child receives*

Individual Specific Needs

The below information will help us to get to know the applicant better. In addition, it helps determine staffing needs and scheduling for the summer program. No answer will prevent admission into the program. Openings are based on program capacity.

Does the applicant have any additional diagnoses or medical concerns/needs? For example, seizures, diabetes, special diet, asthma, life threatening allergies, etc.*

Yes
No

If yes, please list and describe.*

Please let us know what the applicant is doing during a typical day*

What grade will your child be in fall 2024?*

What is the name of your child’s school?*

Please select level of support your child requires most of the time in home or school/community settings in order to be successful*

How does your child communicate?*

Does your child have a history of mental health concerns (severe anxiety, PTSD, self-harm, suicidal ideation/attempts), emergency service (EMS, police, etc.) enlisted to manage behavior, or crisis placement (short or long term)?*

Yes
No

If yes, please provide more details surrounding these concerns and include the frequency and any treatment/services received to address the concerns*

What level of additional support does your child require for behavioral needs?*

If significant support is needed, please describe

If you child attends this program, please describe your primary goals for his or her participation:*

IMPORTANT NOTE REGARDING ATTENDANCE: Due to the demand for this program and the need to customize training and staffing to the unique needs of those who attend, consistent attendance is required. It is our goal to ensure that we maximize our capacity each day so as many individuals as possible are able to benefit from this program.  Failure to attend without cause and/or notification may result in our need to reassess individual needs and participant priority. 

Social Recreation Interest Form – East

Program Participant Info

Contact Information

Service Eligibility

Individual Specific Needs