NEAT Speech at the Beach Registration Event address, date, and timesCamp Harkness 301 Great Neck Road Waterford, CT 06385 Sunday, July 28 10:00 a.m.-2:00 p.m.; Registration begins at 9:30 a.m.Personal InformationChild's first and last name* Child's Age* Person filling out this form?*First and last name, please What is your relationship to this child?* What is your email address?* Is this child ambulatory?*If not, specify what your child uses to help him/her get around (i.e., wheelchair, crutches, walker, etc.) Does this child have vision or hearing concerns?*If yes, please explain. Will this child need any reasonable accommodations for this event?*If yes, please explain. Please list any allergies this child has* Who will be accompanying this child to Speech at the Beach?*Please include their phone number. Communication InformationWhat device and software/application is this child using?*(e.g., iPad with Snap + Core First; NovaChat with TouchChatHD w/ WordPower, BIGmack, GoTalk) How does this child make selections on his/her device?* Direct selection (i.e., uses hand to touch screen) Eye gaze One switch Two switches Other What is your child’s proficiency with device?* Independently with minimal prompting with maximum prompting How often is the device used at home?* Always Sometimes Never What is the biggest communication challenge at home?* Is there an AAC strategy you would like to learn more about to address this challenge?* Will the person accompanying the child be bring a smart device?*If so, what kind (e.g., iPhone, Samsung, iPad, etc.) Important Reminders1. The beach will be open until 6 p.m. with a lifeguard! If you would like to stay at the beach following our event, you are welcome to stay. 2. Food will not be provided. Please bring your own lunch. 3. Make sure to check your email closer to the date of the event for important reminders!Payment InformationThe cost of this event is $20/family (up to 5 people). Please submit payment by July 1 to secure your registration. Cash, Check, MasterCard, Visa or Discover accepted. Checks can be written to NEAT, an Oak Hill Center. Please complete and submit this form. Also, submit payment to Elena Fader, AAC Specialist through one of the options below: Credit card payment accepted online through PayPal or via phone: Pay via PayPal Or, call (860) 286-3119 Mail: NEAT, An Oak Hill Center 120 Holcomb Street Hartford, CT 06112 Attn: Elena Fader Release of Photos/VideosName of Individual participating in event.*First and last name of the child, please. Please choose the appropriate photo/video permissions below* I hereby authorize NEAT, an Oak Hill Center, to take photos/videos of above individual, store them securely, and share them beyond the family/team to demonstrate technology usage or educate others about the impact of AT. (This can include The NEAT Center at Oak Hill marketing materials and website as well as training materials.) I DO NOT authorize NEAT, an Oak Hill Center, to take photos/videos of this child. Signature*Please type your name here as if you were signing. By typing your name here you are effectively signing off on your choice for the photo/video release Dates this release choice is valid forEnter start and end dates for which this release applies.
