Self Determination Program

OMG - Self Determination Program Registration Form

If paying with SDP funding, please complete the form below.
Camper's Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Home Phone Number:*

Area CodePhone Number
Mobile Number:

Area CodePhone Number
Email Address:*
Desired Name Tag:*
Primary Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Select Camp shirt size:*

SmallMediumLargeExtra-large
Please provide any medical or dietary restrictions you have:
How did you hear about Camp?:*

Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*

Area CodePhone Number
Relationship to Student:*

Camper Information

Art. Athletics. Adventure.
Child's Name:
Child's Age:
School:
Regional Center?:*
FMS Provider name (Please note we do not accept Aveanna FMS): *
FMS Provider address: *
What camp will your child be attending?
What camp will your child be attending? (if more than one, you will need a registration form for each camp.)*
Will you require OMG Home Transportation Services?*
If your child requires 1-on-1 support during camp, their caregiver or ABA therapist is welcome to attend. Caregivers who will participate in field trips or access meals/snacks are asked to pay a support fee of $125/day per session for 5-day camps and $25 per day for 1-day camps. Families using Self-Determination funding may request reimbursement for this expense. Please contact us to confirm your support staff’s participation and schedule.
Will child's personal caregiver/ ABA therapist be attending?
Therapist name:
Is your child currently taking any medications?*
If yes, please list medication(s), dosage and reason for use. Please include any important instructions we should be aware of during camp hours.: *
OMG YOUTH SPORTS WAIVER AND RELEASE OF LIABILITY

In consideration for my child(ren) being allowed to participate in sports activities organized by OMG Youth Sports and OMG Adventure Club, I, the undersigned parent or legal guardian, hereby agree to the following:

1. I understand and acknowledge that participation in sports activities involves inherent risks, including but not limited to, the risk of injury, illness, and property damage.

2. I acknowledge that OMG Youth Sports and OMG Adventure Club have taken reasonable steps to provide a safe and controlled environment for these activities.

3. I release, discharge, and hold harmless OMG Youth Sports, OMG Adventure Club, and their officers, directors, employees, agents, volunteers, and representatives from any and all claims, liabilities, demands, actions, or causes of action whatsoever arising out of any loss, damage, or injury, including death, that may be sustained by my child while participating in these activities.

4. I understand and agree that this release of liability extends to any claims based on the actions, negligence, or fault of OMG Youth Sports, OMG Adventure Club, and their officers, directors, employees, agents, volunteers, and representatives.

5. I waive any right to seek legal action against OMG Youth Sports, OMG Adventure Club, and their officers, directors, employees, agents, volunteers, and representatives for any injuries or damages my child may incur during the course of participation in sports activities.

6. I grant permission for my child to receive emergency medical treatment if necessary, and I agree to bear all costs associated with such treatment.

7. I understand and agree that this waiver and release of liability is binding not only on myself but also on my child's heirs, executors, and administrators.

I have carefully read and voluntarily signed this comprehensive waiver and release of liability.
Confidentiality Statement:
All information provided on this registration form is strictly confidential and will be used solely for the purpose of ensuring the safety, well-being, and appropriate support of your child during our programs. We do not share personal or medical information with outside parties without your written consent.
Name*

First NameLast Name
Signature*

Clear

My Products

SDP/ Regional Center Invoice Processing Fee$25.00

One-time non refundable invoice processing fee. Renews in 1 year.

Initial Evaluation/ Consultation$200.00

Mandatory for all OMG adaptive and Inclusive programs. DO NOT SELECT if covered by SDP/ Regional Center.

Enter coupon

Total $0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

OMG - Self Determination Program Registration Form

Emergency Contact Information

Camper Information

Payment Methods