Online Application

Submit an online application below and we will get back to you shortly!

Please answer all questions as accurately as possible. All information is confidential and for the use of Camelot Centre Staff only.

Once your application is reviewed, staff will be in touch about setting up a tour and interview.

If you wish to print the application, please download the PDF below.

Online Application PDF

APPLICANT INFORMATION

(Individual whom service is required)

Gender

PARENT / PRIMARY CAREGIVER INFORMATION

(Individual completing the form)

Phone

PRESENT LIVING ARRANGEMENTS

Parental HomeGroup HomeOther (split living, etc. please specify)

FORMAL DIAGNOSIS AND MEDICAL CONDITIONS

CURRENT MEDICATIONS

NoneFor health concernFor epilepsy/seizuresFor mood, anxiety, sleep or behaviourOther (please specify)
Will medication need to be administered during the 8:30am – 3:30pm day?

ALLERGIES AND FOOD SENSITIVITIES

(please list clearly)

Is an auto-injector required?

MOBILITY

FORM OF COMMUNCTION

PAST DAY ACTIVITIES

Day Program
School
Other

LEVEL OF INDEPENDENCE

Independent completely
YESNO
Can be left alone for short periods of time
YESNO
Requires constant supervision
YESNO
Requires prompts/reminders
YESNO
Will wander
YESNO
Able to follow verbal instructions
YESNO
Needs hand over hand assistance for manual tasks
YESNO

SELF CARE

Toilets themselves independently
YESNO
Needs assistance with personal care/toileting
YESNO
Able to wash hands
YESNO
Able to feed themselves
YESNO
Able to dress themselves
YESNO
Needs assistance with shoes, boots or outerwear
YESNO

LITERACY SKILLS

Can write own name
YESNO
Can write words
YESNO
Able to read
YESNO
Can identify letters
YESNO
Can identify numbers
YESNO
Understands money
YESNO

BEHAVIOURAL CHALLENGES

PERSONAL INTERESTS

(Please check all that apply)

CookingReadingMoviesComputer/InternetHikingScienceSportsBakingColouringDancingSocializingMusic/InstrumentsMathPhysical EducationCraftsArtSingingAnimalsPedestrian and Transit SkillsLegoWriting

COMMENTS

HOW DID YOU HEAR ABOUT US?

WebsiteBrochureOther (please specify)

DAYS OF THE WEEK REQUIRED

(Check all that apply)

MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYMONDAY-FRIDAY INCLUSIVE

SIGNATURE

(Individual completing the form)

Online Application
Skill to Heal

Knowledge Makes
All the Difference

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Miracles of Hope

Your Family Is
in Good Hands

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Online Application
Online Application
Intensive Caring

We Help You Choose a Better Heath Care Facility

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Request a Call Back

We can call you back

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Have A Question? Get In Touch!

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