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Summer A.C.E. Form

  1. Please DO NOT sign or create an account to use this form. www.RoanokeCountyParks.com does not utilize this feature.

  2. The following form is required for participation in Summer A.C.E. from Therapeutic Recreation Services of the Roanoke Valley. Please review all information in the A.C.E. brochure before completing this form. Registration is not considered complete until all forms and deposit are received. All NEW participants of A.C.E. must schedule a pre-registration screening interview to determine appropriateness before registration will be considered complete.

  3. Residency*

  4. T-Shirt Size:*

  5. Please select the weeks or days your participant is attending (check all that apply)

  6. Week 1: June 10-14

  7. Week 2: June 17-21

  8. Week 3: June 24-28

  9. Week 4: July 1-5 (no 7/4)

  10. Week 5: July 8-12

  11. Week 6: July 15-19

  12. Week 7: July 22-26

  13. HEALTH / MEDICAL HISTORY

  14. Does participant have a physical disability?*

  15. Does participant use (check all that apply):

  16. Check areas that apply and explain symptoms below, treatments and actions to take:

  17. PERSONAL CARE NEEDS

  18. Check personal care areas that apply:

  19. Will a medical care provider or 1:1 staff member be attending camp?*

  20. Any staff that will be attending camp with an ACE camper that is not employed with Roanoke County will need to complete a Volunteer Form, Child Protective Services Form, and a complete a Criminal Background Check.

  21. MEDICAL ADMINISTRATION

  22. Will medication need to be administered during ACE?*

  23. Is assistance Needed in administering these medications? (If yes, a request for medication administration form must be completed. These forms are enclosed in the ACE parent handbook, distributed to parents after their child has been accepted into hte program.*

  24. TEACHER RELEASE FORM

  25. Can we speak with the teacher regarding you child's needs and IEP goals?*

  26. EMOTIONAL/SOCIAL/BEHAVIORAL INFORMATION

  27. Is the participant generally:

  28. Does the participant have a current behavior plan?*

  29. Leave This Blank:

  30. This field is not part of the form submission.