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

    Please indicate which Program you are applying for:*

    Please indicate which weeks

    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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