Last name: 

First name: 

Email address: 

This field is required.

Collection Notice:

The information on this form is collected under the authority of the University Act (R.S.B.C. 1996, c.468). It is collected, protected, used, disclosed and retained in compliance with the Freedom of Information and Protection of Privacy Act (R.S.B.C. 1996, c. 165). This information is being collected for the purpose of registering participants attending the Faculty of Applied Sciences (FAS) Outreach Programs. If you have any questions about the collection and use of this information please contact the FAS Manager of Outreach and Diversity at fas_outreach@sfu.ca or 778-782-7020.

Instructions:

The Faculty of Applied Sciences (FAS) Outreach Unit works in partnership with our families to offer an accommodating and inclusive program experience. Youth that require additional supports will be integrated into our program provided the required supports can be met without compromising the safety and security of staff, volunteers, and participants. Integration of youth that require additional supports will be assessed on a case‐by‐case basis by staff in partnership with the parent(s)/guardian(s).

Please fill out this form so that we can best support your child at our program. The information you share will remain confidential but will be shared with our instructors working directly with your child to allow for a positive program experience for all. We require the submission of this form as soon as possible, or at minimum, three weeks prior to the program's start date.

At FAS Outreach we wish to ensure:

• where possible our programs and facilities are accessible
• activities will be adapted to accommodate participants' abilities
• program supports will be provided to facilitate participation of youth who require minimal supports

Support Worker Policy:

At the request of either the parent(s)/guardian(s) or program coordinator/manager, parents may be required to make arrangements to supply their own Personal Care Worker to accompany their child during the day. The Personal Care Worker must supply a Criminal Record Check to FAS Outreach at their own expense two weeks before the commencement of program. The Personal Care Worker will take full responsibility for the care and well being of the assigned participant; they will not discipline or correct other children in the program.

Please provide your first and last name below.: 

Please provide your child's first and last name below.: 

Please provide your contact email below.: 

Which program will your child be attending?: 

• Week 1 App Dev (July 2-5)
• Week 2 App Dev (July 8-12)
• Week 3 App Dev (July 15-19)
• Week 4 App Dev (July 22-26)
• Week 5 App Dev (July 29-Aug 2, All Girls)
• Week 6 App Dev (Aug 6-9)
• Week 7 Invent the Future (Aug 12-16)
• Week 8 Invent the Future (Aug 19-23, All Girls)

Question 1:

Does your child have any accessibility needs or accommodations of which we should be aware? Please describe below.

Question 1 Answer: 

Please indicate "NA" if the question is not applicable to your child.

Question 2:

Please describe in detail the supports that are required for your child to take part in activities.

Question 2 Answer: 

Please indicate "NA" if the question is not applicable to your child.

Question 3A:

Does your child require assistance with daily tasks such as eating, going to the washroom, sunscreen, dressing, or moving from place to place?

Question 3A Answer: 

• Yes
• No

Question 3B:

If yes, will you be providing a Personal Care Worker to assist your child at the program with these tasks?

Question 3B Answer:

• Yes
• No

Question 3C:

If no, please describe in detail the assistance needed.

Question 3C Answer:

Question 4A:

Does your child use any assistive devices?

Question 4A Answer: 

• Yes
• No

Question 4B:

If yes, please indicate the name and function of the equipment.

Question 4B Answer:

Question 4C:

Please describe the proper maintenance and handling of the device(s).

Question 4C Answer:

Question 5A:

Does your child require the administration of medication?

Question 5A Answer: 

• Yes
• No

Question 5B:

If yes, who will provide this care and/or administer the medications?

Question 5B Answer:

Question 6A:

How does your child prefer to communicate?

Question 6A Answer: 

• Speaks clearly
• Uses sign language
• Speaks but may be difficult to understand
• Uses communication board
• Gestures
• Other, please specify below.

If you selected "other" to question 6A, please explain below:

Question 7:

Please list the language(s) your child speaks and understands.

Question 7 Answer: 

Please indicate "NA" if the question is not applicable to your child.

Question 8:

If your child has a Behavior Intervention Plan (BIP) or Individualized Education Program (IEP) at school, please attach a copy here.

Question 8 Answer:

Question 9:

How would you describe your child's personality and approach to developing relationships with adults and peers? E.g. slow to warm up, outgoing, quiet, etc.

Question 9 Answer: 

Please indicate "NA" if the question is not applicable to your child.

Question 10:

What strategies and accommodations can our team incorporate to best support your child’s at FAS Outreach Programs? E.g. visual schedules, timers, quiet time, etc.

Question 10 Answer: 

Please indicate "NA" if the question is not applicable to your child.

Question 11:

Are there any dislikes, environmental triggers, or ongoing significant life events that could impact your child's wellbeing while at FAS Outreach Programs? E.g. loud noises, small spaces, perceived unfairness

Question 11 Answer: 

Please indicate "NA" if the question is not applicable to your child.

Question 12:

Please describe a situation in which your child has been well supported. What factors contributed to this successful experience?

Question 12 Answer: 

Please indicate "NA" if the question is not applicable to your child.

Question 13:

If there is any other information that would assist us in supporting your child’s time during the program, please provide it below.

Question 13 Answer: 

Please indicate "NA" if the question is not applicable to your child.

Question 14:

I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Question 14 Answer: 

• Yes, I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

This field is required.