2. Please DO NOT sign or create an account to use this form. www.RoanokeCountyParks.com does not utilize this feature.
4. 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.
6. Participant Name:*
7. Residency*

   1. Roanoke County
   2. City of Roanoke

   1. Salem
   2. Other
9. Primary Phone Number*
11. What is your/participant's goal for attending ACE? (social, ADLs, physical) Please explain:*
13. T-Shirt Size:*

    1. Youth Medium
    2. Youth Large

    1. Adult Small
    2. Adult Medium

    1. Adult Large

    1. Adult Extra Large
15. Please select the weeks or days your participant is attending (check all that apply)
17. Week 1: June 5-9

    1. All Week
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
18. Week 2: June 12-16

    1. All Week
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
19. Week 3: June 19-23 (no 6/19)

    1. All Week
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
20. Week 4: June 26-30

    1. All Week
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
22. Week 5: July 3-7 (no 7/4)

    1. All Week
    2. Monday
    3. Wednesday
    4. Thursday
    5. Friday
23. Week 6: July 10-14

    1. All Week
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
24. Week 7: July 17-21

    1. All Week
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
25. Week 8: July 24-27 (no 7/28)

    1. All Week
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
27. Anticipated Drop-off Time:*
28. Anticipated Pick-Up Time:*
30. Number of Weeks Requested ($25 deposit per week required)*
31. Amount Due at Registration*
33. HEALTH / MEDICAL HISTORY
35. Does participant have a physical disability?*

    1. Yes
    2. No
37. Does participant use (check all that apply):

    1. Wheelchair
    2. Walker

    1. Cane
    2. Crutches

    1. Other
39. If specialized equipment is used, please list and give instructions for use.
41. Check areas that apply and explain symptoms below, treatments and actions to take:

    1. Seisure Disorder
    2. Visual Impairment

    1. Hearing Impairment
    2. Asthma

    1. Respiratory Disorders
    2. Contagious Diseases (HIV, AIDS, Hepatitis)

    1. Communication / Speech Disorder (please describe method of communication below)
43. Comments about above impairments:
45. PERSONAL CARE NEEDS
47. Check personal care areas that apply:

    1. Dressing
    2. Toitleting
    3. Diapering
    4. Transferring
    5. Feeding
    6. Personal Hygiene
48. Explain personal care needs here if applicable
50. Will a medical care provider or 1:1 staff member be attending camp?*

    1. Yes
    2. No
52. 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.
54. Name:
55. Contact Number
57. Name:
58. Contact Number:
60. Name:
61. Contact Number:
63. Agency:
65. MEDICAL ADMINISTRATION
67. Will medication need to be administered during ACE?*

    1. Yes
    2. No
68. 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.*

    1. Yes
    2. No
70. TEACHER RELEASE FORM
72. What school does your child attend?*
73. Who is their lead classroom teacher?*
75. Teacher's Phone Number:*
76. Can we speak with the teacher regarding you child's needs and IEP goals?*

    1. Yes
    2. No
78. EMOTIONAL/SOCIAL/BEHAVIORAL INFORMATION
80. How does the participant interact in groups?*
82. What are some favorite activities, interests or hobbies?*
84. What activities does the participant dislike?*
86. Please list and explain any activities the participant should not attempt:*
88. Is the participant generally:

    1. Cooperative
    2. Shy

    1. Aggressive
    2. Sensitive

    1. Happy
    2. Angry

    1. Independent
90. List other behavior characteristics of the participant:
92. List areas of frustration for the participant:
94. What types of behavior support are used, and which are most effective?*
96. List some positive reinforcements:*
98. List any other information which will assist ACE staff while working with the participant:
100. Does the participant have a current behavior plan?*

     1. Yes
     2. No
Leave This Blank:


102. 1. Receive an email copy of this form.
103. Email address

     This field is not part of the form submission.

104. Submit

* indicates a required field