Reveal To Heal Life Enrichment Camp Registration Form
Camper's Information
Personal & Health & Contact
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
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2015
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2012
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1928
1927
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1924
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Year
Age (at time of camp)
*
Please Select
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18+
Grade (entering this fall)
*
Who resides in the home with the child?
*
When 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?
hyperactive
angry/aggressive
bossy
lazy
sassy
calm
distractable
withdrawn
moody
driven(wants to learn everything)
Other
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?
*
Parent / Guardian Information
(All correspondence and invoices will be sent to this person)
Name
*
First Name
Last Name
Email
*
example@example.com
Work Phone
*
Cell Phone
*
Relationship to Camper
*
Parent # 1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
Parent/Guardian # 2
First Name
Last Name
Cell Phone
Emergency Contacts and Authorized Pick Up Person
*
Emergency Contacts and Authorized Pick Up Person
Emergency Contacts and Authorized Pick Up Person
Insurance Health Information (to be billed for therapy sessions)
Name of primary insurer
Date of Birth of primary insurer
Type of insurance (through employer or New Jersey Medicaid)
Front of Card
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of
Back of Card
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Select camp week(s) your child would be attending:
*
Jun 24 - Jun 28
Jul 1 - Jul 3
Jul 8 - Jul 12
Jul 15 - Jul 19
Jul 22- Jul 26
Jul 29 - Aug 2
Aug 5 - Aug 9
Aug 12 - Aug 16
Aug 19 - Aug 23
My child will attend every Week
Other
Driver's License
*
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Cancel
of
I will pay $280 weekly using:
*
Debit/Credit Card
Cash
Performcare FINANCIAL ASSISTANCE
DCPP FINANCIAL ASSISTANCE
Program for Parents
I have a open case with DCPP
YES
NO
I agree to use my health insurance for my child(ren) to attend creative therapy 3x per week via (group, family, and individual):
Health Insurance
I need before care: Additional $20 per day or $60 per week starting at 7:30am
*
YES
NO
SOMETIMES
I need after care: Additional $20 day or $60 per week per 4:30pm to 5:30pm
YES
NO
SOMETIMES
Do you need transportation (an additional cost of $100 per week)?
*
YES
NO
What time does your child need to be picked up and dropped off? Please be specific.
Terms & Conditions
OPTIONAL: I am ready to pay the registration fee of $100 to secure my child(ren) seat. Please send the payment link to my cell phone number above.
YES
NO
Pay the Registration fee of $100 per child. ($25 discount per child)
Drop my child (ren) on time at 8:30am
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.
How did you hear about us?
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
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