Summer Camp: Superhero

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Child's Name: *

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Age:

Address: *

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I am interested in: *

Superhero in Training (ages 4-8) • Monday-Friday (June 6-17) • 3:00 PM-5:00 PM **WAITLIST ONLY**

How did you hear about our Superhero Program? *

Parent's Name: *

First Name Last Name

Home Phone: *

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E-mail *

Emergency Contact Name:

Emergency Contact Phone Number

Area Code Phone Number

List any previous diagnoses:

List any previous treatment at STAR Institute or other places: (include any current or previous therapies and testing)

Please describe your concerns for your child in regards to social interaction:

Your child's interests:

Describe play on the playground with other children:

Describe your child's current language skills: (length of sentences, how many step directions can he/she follow, does he/she answer questions, how easily can he/she be understood by peers)

Does your child have any sensory sensitivities (ex: auditory, tactile, etc.?)

Does your child have physical challenges?

Does your child have any allergies or other important medical conditions? *

Your child's preferred t-shirt size *

Will you be receiving Developmental Pathways funding for this group? *

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Will you be receiving funding from Rocky Mountain Human Services? *

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Enter the message as it's shown *

By clicking submit, I acknowledge a deposit of $150 is required to secure a spot in a group. 30 days-notice prior to the start date of a group is required to cancel. If less than 30 days-notice is given, I recognize that the deposit will be forfeited.