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Retreat Application For August/September 2022 Retreat
Name:
Email:
Phone number
Address
Name of person on the spectrum:
Person's diagnosis
Age of person on spectrum
Gender of person on the spectrum
Female
Male
Other
How many people attending?
1
2
3
4
5
6
Who is attending? (Names, and relationship to child on spectrum, ages of siblings)
Special Dietary needs?
Yes
No
If YES, please list dietary needs
Any medications?
YES
NO
IF YES Please list medications
Any behaviors?
Yes
No
If YES, please list behaviors
Any self harming behaviors?
Yes
No
If YES, please list self harming behaviors
Toilet trained?
Yes
No
Does your child on the spectrum attend school?
Yes, typical classroom
Yes, special needs classroom
Alternative education
Do siblings attend school?
Yes
Alternative education
What are you seeking most from this retreat? What are you needing help with?
Specialties: Please tell us anything you would like us to know about your child that would help us to support them better?
Is there anything we should know about your family to help better support you and your children?
Thank you for contacting us.
We will get back to you as soon as possible
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Our Location
We are based in Weldon, California.
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The Awaken Project
3135 S Kelso Valley Rd
Weldon, CA 93283
Main Tel. No.:
760-378-3877
Alternate Phone No.:
619-708-0602
Email: familyawaken@gmail.com
Contact Person:
Annamarie Sandoval or Tirza Dawn
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