Sensory Summer Camp Pittsburgh 2025
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Name
*
First Name
Last Name
Child's Age
*
Child's Grade Level
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's T-Shirt Size
Please Select
YS
YM
YL
YXL
S
M
Is Child Daytime Potty Trained
*
Please Select
Yes
No
Emergency Contact
*
First Name
Last Name
Emergency Contact Relationship to Child
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have any diagnoses?
*
Yes
No
If Yes, please describe any diagnoses below:
*
Does your child have any allergies/special needs?
*
Yes
No
If Yes, please describe any allergies/special needs below:
Does your child bite, hit, or have any aggressive behaviors?
*
Yes
No
If yes, please explain triggers and any strategies that you use to manage aggression:
Is your child generally able to participate in group activities without walking away or attempting to leave the activity?
*
Yes
No
If no, please explain:
Is your child fully potty trained?
Yes
No
Please describe your child's strengths in a few sentences.
Please describe your child's biggest challenges and list any potential triggers that could cause dysregulation such as loud noises, proximity to non preferred foods, swinging, etc.
What would you like to see your child get out of camp?
Consent and Agreement
I give permission to Your Kid's Table, LLC, and it's employees and volunteers, to provide treatment and services at the camp.
*
Please Select
Yes
No
In case of emergency, I understand that every effort will be made to reach the emergency contact listed on this form. If the emergency contact cannot be reached, I hereby give Your Kid's Table, LLC permission to act on my behalf in seeking emergency treatment for my child in the event that such treatment is deemed necessary. I give permission to those administering emergency treatment to do so, using necessary measures. I absolve Your Kid's Table, LLC from liability in acting on my behalf in this regard so long as Your Kid's Table, LLC is not grossly negligent. I further understand that all treatment costs (ambulance, emergency room fees, etc.) are my responsibility.
*
Please Select
Yes
No
Throughout the camp, we will be capturing photos and videos. I understand and allow the images to be used in print publications, online publications, websites, and social media applications. I understand that by selecting "No", Your Kid's Table, LLC will work to exclude my child from all photos and videos, but cannot guarantee it.
*
Please Select
Yes
No
Release of Liability: I release Alisha Grogan and Your Kids Table LLC contractors and volunteers from any and all liability arising from illness, injury, and damages suffered as a result of participation in this camp or traveling to and from this camp. Your agreement to this statement certifies compliance to this information. By providing approval below, I, the parent/guardian, acknowledge, appreciate, and agree to the terms stated above.
Please Select
Yes
No
Submit
Should be Empty: