Day Camp Registration Form

Name*

First NameLast Name

Birth Date*

MonthDayYear

Age (at time of camp)*

Grade (entering this fall)*

Who resides in the home with the child?*

What is the last day of school?*

What does your child need to improvement on academically mentally socially emotionally? Please be specific.*

What is your child's temperament?

What is your child's favorite thing to do?*

List any allergies and dietary restrictions or N/A*

Medications & Frequency*

Has your child been clinically diagnosed with any mental illness?*

Are there any other acomdations your child (ren) may need?*

Name*

First NameLast Name

Email*

example@example.com

Cell Phone*

Work Phone*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation*

Relationship to Camper*

Emergency Contacts and Authorized Pick Up Person*

Emergency Contacts and Authorized Pick Up Person

Name of primary insurer

Date of Birth of primary insurer

Type of insurance

Front of Card

Back of Card

Select camp week(s) your child would be attending:

Driver's License

What week(s) will your child NOT attend camp?

I will pay $150 weekly using:*

Debit/Credit CardCashPerformcare FINANCIAL ASSISTANCEDCPP FINANCIAL ASSISTANCE

I have a open case with DCPP

YESNO

I agree to use my health insurance for my child(ren) to attend therapy 3x per week via (group, family, and individual):

Health Insurance (copay MUST be paid by parent)

I need before care: Additional $35 per day starting at 7:30am*

YESNOSOMETIMES

I need after care: Additional $35 per day starting at 5:30pm

YESNOSOMETIMES

Pay the Registration fee of $100 per child.
Drop my child (ren) on time at 8:15am
Allowing my child(ren) to attend each day he/she is signed up for the summer day camp.
Pay in full weekly even if my child (ren) does not attend the full week.
Pay at the beginning of each week. I understand if my payment is late, I will be charged a $25 late fee. (If payment is not received by the 2nd week of nonpayment your child would not be able to attend summer camp until full payment is received.)
Allowing my son/daughter to participate in indivdual therapy and group therapy under Reveal 2 Heal's practicing therapist. (If you do not agree please inform staff)
(If using health insurance as a method of payment) Allowing Reveal 2 Heal Consultants to charge insurer's health insurance three times per week for therapy.
Pay all copays necessary to ensure full payment is rendered to the summer camp.
Pay all expenses if health insurance does not cover my child(ren) therapy sessions.
Keep my son/daughter home if they are experiencing Covid like symptoms.
Allowing my child(ren) to wear mask at times when it is necessary.

OPTIONAL: I am ready to pay the registration fee to secure my child(ren) seat. Please send the payment link to my cell phone number above.

YESNO

How did you hear about us?*

Date*

Date

Signature*

Clear

Reveal To Heal Life Enrichment Camp Registration Form

Camper's Information

Parent / Guardian Information

Insurance Health Information

Terms & Conditions