2019 FL Winter Retreat Child Family Member Application

Child Family Member General Information

Complete this application for each of your children under the age of 18.

Family Last Name*

Last

Child's Name*

First Middle Last

Preferred Name*

First

for Name Tag

Who do you live with?*

Address*

Street Address Address Line 2 City State ZIP Code

Email

Last Grade Completed*

Date of Birth*

applicant must be over 16

Gender*

Age*

This is my first time applying for BREAKAWAY:*

What would you like to gain from BREAKAWAY?*

What are your favorite activities?*

Please describe in detail challenging behaviors you may struggle with?*

What usually triggers challenging behaviors?*

What are effective responses to challenging behaviors?*

What are two or three effective rewards/reinforcements?*