WRTS Chesapeake Program Application

We Rock the Spectrum Chesapeake Programs Application

"Finally a place where you never have to say I'm sorry"
All applications are reviewed and processed on a first-come, first-served basis. Once available spots are filled, additional applications will be placed on a waiting list. If you are applying for multiple children, please submit a separate application for each. We reserve the right to decline any application at our discretion.
We Rock the Spectrum Program Application

Please complete all sections of this form and submit when completed. Incomplete forms are subject to rejection.
By submitting your application for the selected program, you acknowledge that We Rock the Spectrum is equipped to support children with moderate medical or behavioral needs. Due to the nature of our services, we are unable to accommodate individuals with severe medical or behavioral challenges. If you believe your child may require one-on-one care or additional support, please contact the camp administration to discuss your specific needs prior to registration.
Participant Information
First Name*
Last Name*
Preferred Pronouns*

SheHeThey
Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please select the program for which you are registering:

Pre-K PrepAfterschool ClubHomeschool ClubSpring Break CampSummer CampBreak Time
Which session are you registering for?

Group A (9am-Noon)Other
If attending spring break camp, please select one of the following options:

Attending the entire sessionAttending less than 3 daysNot applicable
Summer Camp: Please select the sessions you are interested in your child attending:

June 23 to July 4th Aloha SummerJuly 7th to July 18th Bugs LifeJuly 21st to August 1st Deep Sea DiscoveryAugust 4th to August 15th Galactic Adventures
Will We Rock After Care be required after the participant's program ends? This is an additional $18/hour. (This is not available during Summer Camp)

Yes, please register for We Rock CareWe Rock Care is NOT neededNot Applicable Summer Camp
What day(s) will your participant come to the program?

MondayTuesdayWednesdayThursdayFridayNot Applicable Summer Camp
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail*
Address - Same As Child*

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Behavior Support Needs

Please answer the questions pertaining behavior support needs so that we can ensure everyone has a safe & fun experience. If a behavior support plan and 1:1 staff is needed, this is an additional cost. LEAF Behavior Support will provide this service.
Does your child have a diagnosed condition?
Does your child experience any of the following behavioral challenges?

Physical AggressionVerbal AggressionSelf-Injurious BehaviorElopementPICAProperty DestructionTantrumsSkin PickingOther
If you answered "Yes" regarding behavioral challenges, how frequently do they occur on a daily basis?

More than 3 timesMore than 7 timesMore than 15 timesMore than 20 times
Please provide detailed information regarding the behavior support needs of your child:
Please provide details regarding any additional support needs your child may have (e.g., communication, prompting, etc.):
Does your child have any allergies?*

YesNo
If applicable, please list any relevant information, including food or medication allergies:
Please note that we are not authorized to administer any medication to your child, whether prescription or over-the-counter. Do you acknowledge and understand this policy?*

Yes
Does your child require assistance with restroom use? Diaper changes will be done in emergency circumstances only and will incur an additional charge.

Yes, but only promptsSomewhat. My child can use the restroom independently but accidents could occurNo, my child is independent and does not need support using the restroom
What social skills goals do you have for your child (e.g., making friends, sharing, taking turns, following instructions, etc.)?
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
Relation to the camper?
Upload Documents (Behavior Plan, OT Plan, Speech Plan, etc.)

Browse Files

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By signing below, you acknowledge that We Rock the Spectrum is not a licensed childcare facility.
By typing your name, you confirm that all information provided is accurate and true to the best of your knowledge.
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We Rock the Spectrum Chesapeake Programs Application

We Rock the Spectrum Program Application

Participant Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Behavior Support Needs

Emergency Contact - Other than Parent/Guardian