Short Intake Summer Camp Detailed Registration Form

Language and Literacy Camp

Thank you for your interest in our camp. We are excited to learn more about you and your child and get you registered for one (or both) of our sessions. Please visit www.rootedincolor.com/summer-camp-info for camp details such as pricing and schedules.
Camper's Information
Child's Name

First Name Last Name
Birth Date

Month Day Year
Grade (as of 2022-2023 school year)
Gender

Male Female Other
Parent/Guardian Information
Name

First Name Last Name
Home Number
Cell Number
E-mail
example@example.com
My child will participate in the following weeks of camp

August 15-19 (half day) August 15-19 (full day) August 22-26 (half day) August 22-26 (full day)
Does your child have any known diagnoses?

Yes No
Please indicate diagnoses

Autism Spectrum Disorder Language Delays/Disorder Dyslexia Articulation Delay/Disorder Motor Delays Intellectual Disability Other
If you are interested in one on one call with Ranita Anderson PhD, CCC-SLP to discuss camp options please use the following link: https://calendly.com/rootedincolor/campinterest
What's next? After completion of this intake you will receive confiirmation of availabiltiy as well as a long form asking more details about your child and their needs. In addition, you will also recieve an invoice for payment to reserve your spot for your selected session(s).
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Language and Literacy Camp