2023 Summer Camp Detailed Registration Form

Summer Camp Registration

This form is not a guarantee of camper participation. You will be contacted our Camp Director Natasha Pratt (919-357-2539; npratt@arctriangle.org) with next steps.
Participant Information
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender Identity*

MaleFemaleNon-BinaryChoose not to answerOther
Race/Ethnicity (check all that apply)*

Asian/Pacific IslanderBlackLatinXNative American/Alaskan Native AmericanWhiteChoose Not to AnswerOther
Primary Diagnosis*
Secondary Diagnosis (if applicable)
Supervision (check one)*

Participates in a group setting independentlyParticipates in a group setting independently for short periods of timeParticipates in a group setting with one-on-one support
Does the camper require one-on-one support in the classroom (or did they when they were in school) or with other services?*

YesNo
Please explain
Current Grade/Classroom Type (if applicable)
Does the camper have the Innovations Waiver (Medicaid Services through Alliance or Vaya Health)*

YesNo
If yes, which agency provides the services?
Will the camper attend with their own support staff? (Medicaid staff, private pay staff, etc.)*

YesNo
Camper guardianship status*

Camper is under 18 years of age, parent(s) are legal guardiansCamper is their own legal guardianCamper has a sole legal guardianCamper has co-guardiansOther
Please upload guardianship documentation, if applicable.

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Parent(s)/Guardian(s) Information
Parent/Guardian 1*

First NameLast Name
Emergency Contact?*

YesNo
Phone Number*
Email*
example@example.com
Parent/Guardian 2

First NameLast Name
Emergency Contact?

YesNo
Phone Number
Email
example@example.com
Emergency Contact (if different from above)

First NameLast Name
Relationship
Phone Number
Length of Day (Drop-Off 8-9am; Pick-Up 4-5pm; half day DO/PU 12:30)*

Full day (9:00-4:00)Half Day - AM (9:00-12:30)Half Day - PM (12:30-4:00)
Choose your week(s) [some weeks are full- contact Natasha if you want to be put on our waiting list]*

6/12-6/167/3-7/7 (CLOSED 7/4)7/10-7/147/17-7/217/24-7/287/31-8/4
Will your camper require medication on the premises (routine or emergency)?*

YesNo
Does your camper have a behavioral plan in place*

YesNoN/A
If yes, please upload it here.

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Would you like information on financial assistance? (Financial aid is very limited. Proof of family income will be required.)*

YesNo
Photo of Camper*

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T-shirt Size*

Adult SmallAdult MediumAdult LargeAdult XLAdult XXL
What else do you want us to know?
Other insightful documents (Psychological, IEP, etc.)

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Registration Fee (Only refundable if camper is not accepted into the program)*

Non-Refundable* Registration Fee (will be applied to camp fees)

$100.00

Total

$0.00

Credit Card

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by The Arc of the Triangle, Inc. dba Triangle Disability & Autism Services during Building Abilities Summer Experience. In exchange for the acceptance of said child’s candidacy by Triangle Disability & Autism Services, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Triangle Disability & Autism Services and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against The Arc of the Triangle, Inc. including all employees and affiliates, all other participants, sponsoring agencies, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization As Parent and/or Guardian of the named participant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child or legal ward, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Triangle Disability & Autism Services including Directors and employees to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

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Summer Camp Registration

Credit Card