Summer Fun Explorers Registration for those with OPWDD Services
Use this form to register for Jimmy Vejar Summer Fun Explorers 2026 at CPW only if you have OPWDD waiver eligibility. One form per participant; those with multiple program participants will need to fill out multiple forms.
Once your registration has been submitted,
please complete and print out
the full application packet, available HERE
(packet will also be emailed after submission).
Today's Date
/
Month
/
Day
Year
Date
Name of Program Participant
*
First Name
Last Name
Program participant will be attending JV Summer Fun Explorers during these dates
*
June 29 - August 7, 2026 (Full regular session)
August 10 - 14, 2026 (additional week)
August 17 - 21, 2026 (additional week)
August 24 - 28, 2026 (additional week)
Other
If you selected "Other" please specify below
Date of Birth
*
/
Month
/
Day
Year
Date
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.
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Relationship to Program Participant
Mother
Father
Other Guardian
If you selected "Other" please specify below
Phone Number (Home)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Work)
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Cell)
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
Emergency Contacts & Authorized Pick-Up Person(s)
In addition to parents/guardians
Emergency Contact Name
*
First Name
Last Name
Relationship to Participant
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Agreement
Signature
*
Parent/Guardian Signature
Submit
Should be Empty: