Epiphany Summer Camp Application
The Epiphany School of Charlotte: We accept applications on a first-come, first-serve basis. Enrollment is based on the order of receipt of application materials, payment, and each child’s match with our program. Payment is required after enrollment verification.
Student Name
First Name
Last Name
Parent Name
First Name
Last Name
Parent/Emergency Contact Email
example@example.com
Parent/Emergency Contact Phone
-
Area Code
Phone Number
Summer Camp Session Choices
July 19-23, 2021 (Grades 3-8)
August 9-13, 2021 (Grades 3-8)
Student Age
Student Grade Level for 2020-2021
Student Allergies (please list. enter N/A for none)
Student Exceptionality
Autism
Asperger's
PDD NOS
ADD/ADHD
Anxiety
Social Communication Difference
None
Other
Please share about your student's special interests: (ex: sports, music, trains, legos, minecraft)
What social skill(s) would you like to help strengthen for your student? (please list or describe)
Please describe any behavioral considerations we need to know in order to provide your child with a safe and enjoyable summer camp: (ex: anxious, overwhelmed, loud noises are bothersome, difficulty starting a conversation)
How did you hear about Epiphany Summer Camp?
Terms and Conditions: Eligibility: Coed, for children in 3rd - 8th grade with Asperger’s Syndrome, High Functioning Autism, a Learning Disability (LD), Attention Deficit Disorder or Hyperactivity Disorder (ADD/ADHD), PDD, and PDD-NOS, who demonstrate the social maturity and developmental ability to participate successfully in a group recreational setting with only verbal redirection may apply for enrollment. Campers with emotional or behavior disorders as a primary diagnosis are not eligible to apply. The directors may disqualify acceptance to a camper due to: failure to provide accurate information about your child during the application process, or due to significant oppositional or physically aggressive behavior, or due to behaviors that significantly disrupt the experience of other children at camp. Any early departure determination by the camp requires immediate parent/guardian pick up. (I HAVE READ AND AGREED TO THESE TERMS)
Yes, I have read and agree to these terms and conditions
I understand that this is an application. The Epiphany Admissions team will be in touch with me regarding enrollment for my child into summer camp.
Yes, I understand
Digital Signature (first and last name): By signing here, I attest that the above information is true and has been filled out by the parent/guardian of Summer Camp applicant.
Submit
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