Fall 2025 Camp Registration Form

Fall 2025 Camp Registration Form

October 24th - 26th
This year's fall camp will be a trip to Lake Arrowhead. Participants will have the opportunity to practice social skills and gain independence in a fun, relaxed, and refreshing environment.

We will provide transportation to the camp site from our LEAPS Community Hub. Registered campers will need to be at the Community Hub (73726 Alessandro Dr., Suite 102, Palm Desert, CA 92260) by 10:00 A.M. on Friday, October 24th. After successful registration, we will provide you wlith the address of the campsite. Participants will return to the LEAPS Community Hub Sunday, October 26th at 4:30 P.M. and we ask that families arrange for pickup from the hub at that time. We will ask our participants to send a message to their loved ones when they are getting close to the LEAPS Hub.
Name of Camper*

First NameLast Name
Email*
example@example.com
Camper's Date of birth*

MonthDayYear
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Information
Does your child have special instructions for medical treatment? If yes, please explain including the medication your child is taking*
Are there any activities that you wish your camper to not participate in? Please explain below*
Does your camper have or had Asthma, Kidney Disease, Diabetes, Heart Murmur, Seizures, Hay Fever? Please explain below*
Please list any support that the camper may require during their time at the camp (i.e. assistance with toileting, cutting food, etc.)*
Name of Doctor

First NameLast Name
Phone Number

Area CodePhone Number
Consent and Authorization
I, the undersigned, hereby declare and affirm that:

I am the parent/legal guardian of the camper named above (hereinafter referred to as "Child"), who is under my care and responsibility.

I hereby consent and give authority to the participation of my Child in the scheduled activities of the Camp, and all other activities which is supervised and customarily associated with its group.

I hereby declare and affirm that my Child is physically fit to take part in the Camp's activities and my Child has no known illness or adverse medical condition that would render him/her unfit to participate therein, other than the information specified in the medical information above.

I shall immediately advise the organizers in writing, should I discover any illness, adverse medical condition, or any other physical challenges that would render my Child unfit to participate in the recreational and sporting activities of the Camp.

I shall notify the organizers immediately in case I revoke my consent to the Camp for this event.
Authorization for Medical Treatment

I understand that in case of medical emergencies involving my Child, I shall be notified right away. In case any of my provided contact information is unreachable, I authorize the organization to call the doctor indicated above. In case that the doctor is not available, I authorize the organizers to call any doctor to provide the necessary medical attention to my child.

I understand that the camp shall not be responsible, and shall be reimbursed, for any medical expenses incurred by them over this authorization.
Media, Consent, Release, and Waiver
I hereby give consent to LEAPS Services (the “organization”) to photograph, videotape, or otherwise digitally record and use images and/or sound recordings of myself or my child or children (if applicable) to use in any public media, including radio, television, internet, social media, print or in any of the organization’s or its partners’ publications, productions, or posts.

I understand that the intended use of such images and information is solely for the purpose of advertising, marketing, fundraising and/or the promotional and public awareness purposes for the organization.

I hereby waive any rights or interest in the images or recordings, as contemplated in this release.

I acknowledge that this consent to use images and/or recordings is being made solely for the benefit of the organization and comes without any expectation of monetary compensation or other benefit to me. To the extent that any benefit accrues or might accrue to the organization from the use of images or information, I hereby and forever waive any interest in or claim to such benefits.

I hereby release and forever discharge the organization (including without limitation all corporate affiliates and officers, directors, trustees, donors, employees, agents and volunteers) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of images and materials described herein, and I hereby waive all rights and interest in and to such information and materials.

I further acknowledge that there is no guarantee that any or all of the participants’ images or recordings will be used in any released media.

I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying the organization in writing at:

info@leapsservices.com
Name of Parent/Guardian*

First NameLast Name
Contact Number*

Area CodePhone Number
Signature of Parent/Guardian*

Clear
Payment Options*

Pay Today (Venmo or Square) $1,275.00Pay Using Self Determination Program (Community Integration - 331) $1,275.00

To process payment and complete your registration, please use one of the two links below. A tab will open to let you complete payment. Afterwards, please click "Next" to finish registering.

Venmo ($1,275.00)

Square ($1,275.00)

Submission
Please click "Submit" below to complete registration.
Should be Empty:

Fall 2025 Camp Registration Form

Medical Information

Consent and Authorization

Submission