Club Tomodachi Registration

The Entrepreneur Discovery Summer Camp is designed to help neurodiverse students explore the possibility of entrepreneurship as a career opportunity/path. Students will identify their personal strengths, skills, and talents that align with successful entrepreneurship and develop additional understanding and skills needed for the process.

For questions and to get more information, please email EntrepreneurDiscovery@Gmail.com or call 804-554-1870.

Student's Name *

First Name Last Name

Parent/Caregiver's Name *

First Name Last Name

Parent/Caregiver Email *

example@example.com

Parent/Caregiver Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Caregiver Phone Number *

Please enter a valid phone number.

Emergency Contact *

First Name Last Name

Emergency Contact Phone Number *

Please enter a valid phone number.

Student's Birthday *

Date

Student's School *

Student's Current Grade *

During our meetings, students will have the opportunity to play games, participate in discussions, and complete team and individual projects. Will your student require any accommodations or resources to participate in the camp and complete the activities? *

Yes No I am not sure

If yes, please describe

What do you and your student hope to gain by participating in the Entrepreneur Discovery Camp? *

Student medical and/or mental health diagnoses (**If applicable. If none please write n/a in the box below) *

Light snacks will be provided during the meeting. Please list your student's allergies or dietary conditions. (**If none, please write n/a in the box below) *

The Entrepreneur Discovery Summer Camp is a two-week event. Participants must attend both weeks to complete the camp. By clicking the box below, you agree that your student will attend both weeks (Week 1: Monday, July 11th, 2022 through Thursday, July 14th, 2022 Week 2: Monday, July 18th, 2022 through Thursday, July 21st, 2022) 9:00 am - 12:00 pm. **There are no make-up days included and days students do not attend will not be rescheduled. *

I have read this statement and am agreeing my child will attend both weeks

While this is a group that includes lessons and supports to help with social skill development, it may not be appropriate for those who engage in high levels of challenging behaviors. Does your student engage in any of the following behaviors? (**Check all that apply. Answering yes does not guarantee student will not be able to participate) *

Emotional outbursts (crying, screaming, yelling, refusing to participate, disruption of activities, etc.) Verbal aggression (name calling, making threats, using profanity, etc.) Physical aggression (hitting, kicking, pinching, biting, throwing objects at others, etc.) Property destruction (throwing things, knocking things over, punching things, tearing up others items, etc.) Walking off/Eloping (leaving the room without permission, not returning when called back) Interrupting others (talking when others are talking, making rude comments when someone says something they do not understand or disagree with) Refusal to participate (does not participate in group activities and rushes others who do) None

Enrollment in the Entrepreneur Discovery Camp includes all the materials needed to complete the two-week program. Enrollment also includes a light snack that will be provided during the break each day. The Entrepreneur Discovery camp will not provide any lunches (dismissal is at 12 pm), transportation to and/or from the office, or extended hours of care in supervision. Additionally, tuition needs to be paid in full by the first day of camp, July 11th, 2022, unless payment arrangements have been made. Invoices will be sent to the email address entered above when completed applications have been received. Please read through the following statements and click the boxes to demonstrate you understand these conditions and agree. *

I have been notified that the Entrepreneur Discover Camp does not provide lunch for participants. I have been notified that the Entrepreneur Discovery Camp does not provide transportation to or from the office and travel arrangements are needed for my child to attend each day. I have been notified that the Entrepreneur Discovery Camp dismisses students at 12 pm and my student will need to be picked up no later than 12:00 pm as additional supports are not available after 12:00 pm. I understand that tuition needs to be paid in full or payment arrangements made by the first day of camp, July 11, 2022. I understand that when this application has been completed and submitted, I will receive an invoice to the email I shared above for the tuition.

Thank you for completing this application. If you have any questions or need any additional information, please email EntrepreneurDiscovery@Gmail.com or call 804-554-1870.

We look forward to helping your student turn their ideas, talents, and creativity into a successful small business.

Sincerely,

Sandra L. Thompson & Zipporah Levi-Shackleford