Camper Waiting List
Summer 2025
Camper Information
Camper's Full Name
*
First Name
Last Name
Nickname
Age
*
Date of Birth
*
MM/DD/YYYY
Please Choose Day Camp Experience
Little Raven Camp, ages 6-9
Sensory Friendly Camp, ages 9-16
Boys Week, ages 9-16
Girls Week, ages 9-16
Please Note any Special Considerations such as Sleepwalking, Bed Wetting, Night Terrors, Asthma, etc.
Please note any IEP's or diagnosis that would be important for our team to know. Autism, ADHD, Defiance Disorder, HFA, Eloping, Self Harm, etc.
Family Information
Name of Parent or Legal Guardian Signing Camper Up For Camp
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone Number
*
-
Area Code
Phone Number
Text Reminders
Yes
No
Secondary Number if Available
-
Area Code
Phone Number
Email
*
example@example.com
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Please check all the boxes that may apply to the child and the family environment:
Was ever the victim of violence or witnessed any violence in his/her home .
Was the victim of sexual assault or abuse.
Was the target of name calling, swearing, or put down remarks in the home.
Struggled connecting with family members or express the family not being close.
Experienced economic hardship “somewhat often” or “very often”.
Lived with a parent or guardian who got divorced or separated.
Witnessed a parent, guardian, or other adult in the household victim to abuse.
Lived with anyone who had a problem with alcohol or drugs.
Lived with anyone who was mentally ill or suicidal, or severely depressed.
Lived with a parent or guardian who served time in jail or prison.
Had a parent or guardian who died.
Please write a brief description of your child and family history regarding the statements above :
*
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