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Online Application

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

Five people sitting together on a park bench beneath a large tree, with one person using a wheelchair.
Three smiling people standing together wrapped in colourful towels.

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

    July 6 - 10July 13 - 17July 20 - 24July 27 - 31Aug. 4 - 7* (fees for short week - $405)Aug. 10 - 14Aug. 17-21

    APPLICANT INFORMATION (Individual whom service is required)

    Gender*

    MaleFemale

    PARENT / PRIMARY CAREGIVER INFORMATION (Individual completing the form)

    Phone

    Best way to contact you:*

    PhoneEmail

    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?*

    YesNo

    ALLERGIES AND FOOD SENSITIVITIES (please list clearly)

    Is an auto-injector required?*

    YesNo

    MOBILITY*

    Walks without aidsWalks with aidsUtilizes a wheelchair independentlyUses a wheelchair with assistance (e.g. staff will be required to assist them)

    FORM OF COMMUNICATION*

    VerbalVocalizes/makes soundsPEC SymbolsASL or modified signNon-verbal (please specify)

    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*

    YesNo

    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)

    *