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Special Needs Supplement

First Name(s) Last Name Age as of June 1

Home Telephone (country & city code) E-mail address Country

Do you have experience with any of the following? (check all that apply)
q Feeding q Lifting q Seizures q Diapering q Dressing q CPR q First Aid q Bathing q Sign Language q Toileting

Are you willing to do any of the following while at camp? (check all that apply)
q Feeding q Lifting q Seizures q Diapering q Dressing q CPR q First Aid q Bathing q Sign Language q Toileting
If no, please explain. Which of these would you find difficult and why?

Camper disability preference: (check all that apply)


q Mental q Physical q Blind q Emotional q Behavioral Problems q Learning Disabilities q Terminal Illness

Which types(s) of campers would you like to work with? q Adults only q Children only q Open to all options

Please describe your formal training, work experience or school study related to the disabilities field. Give specific examples that
relate to the care of a person (or people) with special needs. If you have no experience with this population, please state that here.

What do you hope to gain from working at a special needs camp this summer?

Your camper suddenly bites another camper and tries to hit you when you approach him. Describe your response: what action
would you take?

Please list two words that describe you and explain why these qualities make you a good candidate for a position at a special needs
camp.

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