** ALL APPLICATIONS MUST BE DONE ONLINE**

Film Camp Student Application
April 23-27, 2018

A teacher or parent will need to help complete this application.
Film Camp registration is limited (50). Applicants will be reviewed and accepted on a first come, first served basis (as long as grade criteria is met). Priority registration will be given to first time attendees. Please note we are keeping spaces open for first time attendees until after the deadline of March 26, 2018. If you attended last year, please submit an application, but we will not be able to notify you of acceptance until March 27, 2018. If you choose to make hotel reservations, prior to March 27, please make sure the reservations are refundable. The cost to attend for students is $75.00 which will cover daily snacks and lunch. The application deadline is March 26.

All students attending the film camp must be in the Arkansas Rehabilitation Services (ARS) case management system. Therefore, applicants selected to attend the film camp will need to meet with their local Arkansas Rehabilitation Services (ARS) transition counselor and provide ARS with a copy of the student's Social Security card, photo ID, copy of the student's IEP, and ARS Informed Consent by March 26 to ensure information is entered into the database in a timely manner.

For further information, contact Bonnie Boaz at (501) 375.6487 or Maryanne Caldwell at (479) 582.1286.

Student Name(*)
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Please enter your first and last name.

Gender(*)
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Street Address(*)

City(*)

State(*)

Zip Code(*)

District(*)
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Please select your district from the list.

Home Phone Number(*)
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Current Grade(*)
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High School(*)

School Phone Number(*)
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Student Email Address(*)
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Parent/Guardian Name(*)
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Please enter first and last name.

Parent/Guardian Primary Spoken Language(*)
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Parent/Guardian Email Address(*)
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Parent/Guardian Phone Number(*)
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Please list the name of a teacher we can contact if more information is needed(*)
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Please enter first and last name.

Teacher's Email Address(*)
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Tshirt Size(*)
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Ethnic Group(*)
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Disability Category (Please select all that apply.)(*)

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Other Disabilities
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Special Dietary Needs
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Requested Accommodations Needed
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Describe the applicant's interests and educational program.(*)
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(Favorite activities, topics of interest, school program, community program, in school and/or private therapies, etc.)

Does the applicant have a full or part time aide at school?(*)
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If yes, what type of services does the aide provide?
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Will his/her aide be attending this film camp?
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How does the applicant understand and interpret information?(*)
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(Reads, uses written notes to assist with auditory understanding, write, uses picture schedule or written schedule, etc.)

How does the applicant communicate?(*)
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What support(s) help the applicant communicate better?(*)

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Please describe:
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What is challenging for the applicant in a large group?(*)

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What challenging behaviors does the applicant experience?(*)
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(Aggression towards classmates/adults, leaving areas without permissions, tantrums, fighting, verbal abuse, refusing to complete work, etc.)

What strategies work well in these challenging experiences?(*)
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Does the applicant...?(*)

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What type of behavioral support does the applicant receive?

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Please describe the frequency of support, how support is provided, if assistants are present/what they do
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(Favorite activities, topics of interest, school program, community program, in school and/or private therapies, etc.)

In what situations is the applicant the most comfortable?(*)
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What situations make the applicant uncomfortable?(*)
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(What happens, what makes the situation worse, what helps most?)

Please list how the student will be transported to the Inclusion Film Camp 2018. List a name and contact number for the person(s) providing the transportation.(*)
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Drop off will be TBD.

Will you be reserving a hotel room for the week you attend camp?(*)
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Enter the letters you see in the field provided(*)
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