Please Complete the

CCC Hangout Application Form

Parent's name

Address

City

Participant's Name

Participant's Date of Birth

Participant's Sex

Participant's Diagnosis

Tell us about your child and any supports he or she may need (e.g., mobility / toileting / behaviour / food sensitivities etc).

What is the participant's interests and strengths?

How would the participant handle not wanting to participate in an activity?

In which areas does the participant require support?

Are there any behavioural issues?

Are there any medications that would need to be given during the program running from 12:30 pm to 4:30 pm? If so, how will they be administered?

What is the best time to contact you?

Form submission[]