Pre-Screening Questionaire for School Holiday Programe Question Title * 1. Full Name of Child: Question Title * 2. Age: Question Title * 3. What is your preference of week? Jan 19-24th Jan 26-31st Question Title * 4. Diagnosis Question Title * 5. What is their preferred communication style? Vocal/Verbal Nonverbal AAC Other Question Title * 6. Your Name: Question Title * 7. Relationship to Participant: Parent Guardian Other (please specify): ___________ Question Title * 8. Contact Information: Phone Number Question Title * 9. What area in Auckland does the participant reside in? Question Title * 10. What would you most like your child to gain from our holiday program? (Select all that apply) Social Skills and making new friends Building confidence and independence Learning new activities or hobbies Improving communication skills Engaging in structured, active play Gaining a sense of routine and structure Other (please specify) Done