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 and Board of Directors 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

Best way to contact you: *

PRESENT LIVING ARRANGEMENTS *

Parental HomeResidential CareOther (split living, etc. please specify)

PAST DAY ACTIVITIES

Day Program
School
Other

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 *

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

ENVIRONMENTAL FACTORS

Sensitive to loud noises. *
YESNO
Requires a lot of personal space (arms length or more) *
YESNO
Sensitive to the heat/sun *
YESNO
Sensitive to the cold/winter *
YESNO

BEHAVIOURAL CHALLENGES

PERSONAL INTERESTS

(Please check all that apply)

CookingBakingCraftsReadingColouringArtMoviesDancingSingingComputer/InternetSocializingAnimalsHikingMusic/InstrumentsPedestrian and Transit SkillsScienceMathLegoSportsPhysical EducationWritingOther

COMMENTS

ASSESSMENTS COMPLETED BY THE DSO

Please attach a copy of any assessments you have access to from the DSO, including but not limited to the Support Intensity Scale (SIS) and The Application for Developmental Services and Supports (ADSS).

Forms Attached *

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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