JAM's Summer Camp Application
May 27 - August 1, 2025 Monday - Friday: 9:30 am - 3:00 pm Cost: $400 per week Ages: 12 and up! Early Bird Discount: Sign up for 3+ weeks by May 1, and receive 10% off! Sign up for 2 weeks by May 1, and receive 5% off total cost! Camp spaces are available on a first-come, first-served basis. Reserve your spot by submitting the application and camp fee! For more information, email kennedy@jamsnonprofit.org Website: www.jamsnonprofit.org
Camper's Name:
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First Name
Last Name
Birth date:
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Age:
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School:
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Grade:
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Gender:
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Please Select
Male
Female
T-shirt Size:
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Please Select
Small
Medium
Large
2XL
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caretaker #1 Name:
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Parent/Caretaker #1 Phone:
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Cell
Work
Parent/Caretaker #2 Name:
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Parent/Caretaker #2 Phone:
*
Cell
Work
Parent's Email:
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example@example.com
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Summer Camp Weeks
Please select the weeks you'd like to register for camp. You can choose to sign up on a month-to-month basis, allowing flexibility in case your plans change.
First Session
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May 27 - May 30
June 2 - June 6
June 9 - June 13
June 16 - June 20
June 23 - June 27
Second Session
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June 30 - July 3
July 7 - July 11
July 14 - July 18
July 21 - July 25
July 28 - August 1
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Emergency Contact (other than parents):
Please list two individuals to contact in case of an emergency where we are unable to reach you:
Emergency Contact #1:
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Name
Relationship
Phone Number
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Please enter a valid phone number.
Emergency Contact #2:
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Name
Relationship
Phone Number
*
Please enter a valid phone number.
Medical Insurance:
Please complete the entire section. If any question does not apply to you, simply write "N/A" in the provided space.
Insurance Company:
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Insured:
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Policy #:
*
Address:
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Medicaid #:
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Medicare #:
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Immunizations up to date?
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Please Select
Yes
No
Medical History/Problems (please check all that apply): Camper has/had:
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Asthma
Diabetes
Seizures
Nosebleeds
Heart Disease
Other
None
If other, please specify:
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Does your child have any of the following allergies?
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Animals
Hay Fever
Pollen
Food
Plants
Insect Stings
Medicine/Drugs
Other
None
If other, please specify:
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If food, please specify:
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Please describe reaction/symptoms seen and interventions needed if reaction occurs:
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Please list any medications your child takes on a daily basis including dosage information: (This information is required even if medication will not be administered at camp)
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Will your child be taking medication while at camp? (You will be asked to fill out a medication form for your child on the first day of camp for any medications that need to be administered during camp hours.)
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Please Select
Yes
No
Please list any medical conditions or mobility restrictions that would prevent or limit your child from participating in any type of outdoor activity:
*
Check the special needs categories that apply to your child
*
Dietary Restrictions
Attention Deficit Disorder
Visually Impaired
Hearing Impaired
Glasses
None
Other
Please specify below:
*
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What type of activities does your child enjoy most?
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List any activities that your child does not enjoy or any fears we should be aware of:
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How does your child tolerate and/or interact with other children?
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Are you aware of any specific sensory needs that your child exhibits?
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What types of rewards or reinforcers are motivating for your child?
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Is your child toilet-trained?
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Please Select
Yes, my child does not require adult assistance in the bathroom.
Yes, my child is toilet-trained but requires prompting and assistance from an adult.
No, my child is not yet toilet-trained.
What type of toileting schedule is your child on and how often are they taken?
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How does your child indicate the need to go?
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How does your child choose to communicate their wants/needs most often? Please the following choices that apply most to your child.
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One word
Two-word phrases
Echolalia (repeats words)
Visual system (PECS)
Augmentative Device
Sign Language
Conversational
Does your child currently have a Behavioral Intervention Plan included in their IEP at school?
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Please Select
Yes
No
If your child has a behavior intervention plan (BIP), you will be asked to bring a copy of this plan to camp.
What specific behavioral needs does your child currently have right now?
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What does the behavior look like? (Ex. biting hand, hitting head on hard surfaces, dropping to the floor, etc.):
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When and how often does it seem to occur?
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How long does the behavior usually last? (Ex. 5 minutes)?
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What type of interventions or calming techniques have you found to be useful in dealing with these behaviors?
*
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Camp Application Fee: A payment of $50 will reserve your spot for camp this summer.
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Application Fee
Reserve your space
$
50.00
Quantity
1
2
3
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5
6
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10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
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