Booster Club 2022 Application Form
Thank you for applying for our 2022 Summer Booster Club. Once you have submitted the following information, someone from the DTS team will contact you to complete your registration.
Todays date
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Month
-
Day
Year
Date
How did you hear about our Booster Club?
*
Primary Caregiver's Information
Full Name (Primary Caregiver)
*
Primary Caregiver's First Name
Last Name
Relationship to Club Member
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Club Member's Information
Club Member's Name
*
Club Member's First Name
Club Member's Last Name
Date of Birth
*
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Month
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Day
Year
Date of Birth
Club Member's Age
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School Attended in 2021-2022 School Year
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Grade for Upcoming 2022-2023 School Year
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School Attending in Upcoming 2022-2023 School Year
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Is your child currently receiving services from DTS?
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Yes
No
Does your child have a diagnosis?
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Yes
No
If yes, what is the diagnosis?
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Who is diagnosing healthcare provider?
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Please describe your child's STRENGTHS
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Please describe your child's CHALLENGES
*
Anything else you want to tell us?
Office Staff Notes Only
Fees Paid?
$125 Evaluation Fee
$75 Deposit
Camp Checklist
Therapist Notified to Screen
Seeking SL/OT Eval
Screening Scheduled
Screening Completed
S/L Eval Needed for Insurance?
Registration Fees Paid
Welcome Pack Sent
Not confirmed
Declined to attend camp
Thank you!
Someone from the DTS Team will be in touch shortly to schedule your child for our Booster Club this summer. We look forward to Lighting Up Learning this summer with your child!
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