Inner Beauty Summer BOOTCAMP

Inner Beauty Summer BOOTCAMP
Date of Referral

MonthDayYear
Date
Client Name

First NameLast Name
Age
D.O.B.
Type of Insurance/Insurance No./
Address / (Family Home, Foster Care, Residential, Etc
Type of Placement (if applicable)
Guardian(s)/Caregiver(s)
Guardian(s) Email
example@example.com
Relationship to Youth
Contact Phone Number
School/District
Grade
IEP?
Any Present Concerns/Risks (Reason for Referral, including any trauma)
Established Diagnosis
Social Goals
The Inner Beauty Summer Bootcamp cost is $55 per week per child. This fee is due each Friday prior to the service week. Payment can be made electronically via cashapp at SChrystallB, PayPal at innerbeautypageant@gmail.com. or Zelleat innerbeautypageant@gmail.com The curriculum guide will be presented to you prior to the initial start date. Field Trips will be a part of the weekly curriculum. Snack and lunch will be provided.

I authorize my permission for my child to attend weekly field trips, participate in physical fitness, engage in meaningful curriculum, hear from guest speakers, and be transported by the approved Inner Beauty Program, Inc. mentors,, junior camp counselors, and volunteers.
Name Of Child
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
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