Summer Splash Camp Registration 2025- @ Cherry Tree

Summer Splash Camp at Cherry Tree

Connections Pediatric Therapies Summer Camps 2025
Child's Full Name*

First NameLast Name
Child's Date of Birth:*
Entering Grade:*
Gender:*

GirlBoy
Primary Language:*
Diagnosis (if applicable):
Is your child:*

SpeakingNon-Speaking
Parent/Guardian Name(s):*

First NameLast Name
Parent/Guardian Name(s):

First NameLast Name
Primary Contact Number (cell)*
Please enter a valid phone number.
Secondary Contact Number (cell):
Please enter a valid phone number.
Email Address:*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Full Name:*

First NameLast Name
Relationship to Child:*
Emergency Contact Cell Phone:*
Please enter a valid phone number.
Does your child have any allergies? If YES please include details. If NO type N/A*
Does your child have any medical conditions we should be aware of? If YES please explain details. If NO type N/A*
Does your child require sensory input/regulation support? If YES, what support works BEST? If NO type N/A*
Does your child requre an EpiPen?*

YESNO
Is your child potty trained?*

YESNO
Does your child require any additional accommodations or support? If YES, please explain. If NO type N/A*
CAMP INFORMATION & POLICIES

1. Camp Expectations
- This is NOT a therapy program. While therapists and trained staff lead camp activities, this is a recreational and skill-building camp, not a direct therapy service.
- Camp counselors include licensed therapists as well as screened high school and college student volunteers under the supervision of professionals.
- We strive to provide a safe, engaging, and structured experience for all campers.
2. Payment & Refund Policy
- All camp fees must be paid in full at the time of registration.
- NO refunds unless a camp week is canceled due to low enrollment.
- Camps require a minimum number of participants. If a week is canceled due to low registration, parents may transfer to another location or receive a refund for that week.
- If your child is currently registered for therapy at CPT, you may apply for reimbursement through Step Up with a superbill AFTER camp. Superbill requests must be made via email to: info@connectionspediatrictherapies.com by May 30th.
3. Drop-Off & Pick-Up
- Drop-off is 10 minutes before camp start time.
- Pick-up is promptly at camp end time.
- Late pick-up may result in additional fees.
4. Health & Safety
- If your child is sick or exhibiting symptoms of illness (fever, vomiting, diarrhea), please keep them home.
- If a child becomes ill during camp, parents will be contacted for immediate pick-up.
5. Behavior Policy
- We strive to provide a positive, structured, and inclusive environment.
- If a child engages in disruptive or unsafe behaviors, parents may be contacted for early pick-up.
- If behavioral concerns persist, removal from camp may be considered.
Photo & Video Release

YES I DO   NO I DO NOT   grant permission for my child to be photographed or recorded during camp for educational or promotional purposes.

Medical Release & Liability Waiver

I, the undersigned, acknowledge that participation in Connections Pediatric Therapies Summer Splash Camp involves activities that may have risks. I understand that reasonable precautions will be taken to ensure my child's safety.

YES*    I hereby release Connections Pediatric Therapies, its staff, and affiliates from any claims related to injury, illness, or damages resulting from participation in camp activities.

YES*   In the event of a medical emergency, I authorize camp staff to seek necessary medical care for my child. I understand that I will be contacted immediately if such an event occurs.

Camp Enrollment Minimum Policy

Connections Pediatric Therapies reserves the right to cancel or modify camp sessions if the minimum number of enrolled children is not met. In the event of low enrollment:
- A camp week may be canceled if there are not enough participants.
- The camp location may be adjusted to be offered only at Connections Pediatric Therapies or Cherry Tree Preschool.
If a camp week or location is canceled due to low enrollment, parents will have the option to:
- Transfer their child's registration to the same camp at an alternate location (if available).
- Receive a reimbursement for the canceled week of camp.
Parents will be notified in advance if a change or cancellation occurs, and alternative options will be provided when possible.

YES*  I acknowledge that camp enrollment is subject to minimum participation
requirements and that adjustments may be made as needed.

Parent/Guardian Agreement & Signature:

I have read and agree to the policies and procedures outlined in this registration form.

Parent/Guardian Name (Print):   First Name*   Last Name*

Signature:   Signature*

Date:   Date*
Please Note: It is a requirement to pay the One-time Registration Fee for the camp you are signing up for and you must choose a minimum of at least 2 weeks of camp.

Continue to choose camps below:
If any portion of this registration is incomplete, either failure to add the registration fee or failure to add at least two weeks of a camp, your registration may be cancelled. Please call our office with any questions. 727-712-0808

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Summer Splash Camp at Cherry Tree

CAMP INFORMATION & POLICIES

1. Camp Expectations

2. Payment & Refund Policy

3. Drop-Off & Pick-Up

4. Health & Safety

5. Behavior Policy

Photo & Video Release

Medical Release & Liability Waiver

Camp Enrollment Minimum Policy

Please Note: It is a requirement to pay the One-time Registration Fee for the camp you are signing up for and you must choose a minimum of at least 2 weeks of camp.

If any portion of this registration is incomplete, either failure to add the registration fee or failure to add at least two weeks of a camp, your registration may be cancelled. Please call our office with any questions. 727-712-0808

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