Child's First Name
Address Line 2
State / Province / Region
ZIP / Postal Code
Parent/Guardian First Name
Parent/Guardian Last Name
Relationship to Student
Emergency Contact Name
Emergency Contact Phone Number
Person(s) authorized to pick up your child:
Person(s) NOT authorized to pick up your child:
Are there any allergies or medical conditions we should know about?
If Yes, Please explain:
Preferred Hospital in Case of Emergency:
What age is your child?
5 - 8 years-old (9am - 12 pm)
9 - 12 years-old (1pm - 4 pm)
Please select each session your child will attend: (check all that apply)
Two days per week (Tues/Thurs)
Three days per week (M/W/Fri)
Please select the weeks you are interested in signing your child up for (check all that apply):
Week 1 (June 13 - June 17, 2022)
Week 2 (June 20 - June 24, 2022)
Week 3 (June 27 - July 1, 2022)
Week 4 (July 11 - July 15, 2022)
Week 5 (July 18 - July 22, 2022)
Week 6 (July 25 - July 29, 2022)
About Your Child
This information will help our team customize the program and ensure your child gets the most they can from the program. We appreciate you taking a moment to fill it out as completely as possible.
Reason(s) you'd like your child to participate this summer?
Has your child/is your child receiving any type of therapy? If yes, please specify.
What are your child's strengths?
Are there any things that are upsetting your child that we need to be aware of?
What would you like your child to gain from this experience?
Is there anything we can do to reinforce/support what you are doing with your child at home?
Should be Empty: