Summer Experience Participation Form 🎉🌞

Summer Program Registration Form

Please fill out this form to register for the summer program and specify your preferences and support needs.
Participant & Guardian Information
Participant Name*
Parent/Guardian Name*
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Participant's Birthday*

MonthDayYear
Date
Date*

MonthDayYear
Date
Participant's Diagnosis*
Participant's Place of Employment (if applicable)
Support Needs & Accessibility
Describe the level of support needed daily*
Level of independence at home*

I live on my own and drive or use special transportationI live with my family/guardian and can stay home aloneI live at home and need someone with me majority of the timeI live at home and need full time support
Level of support needed in the bathroom*

Completely IndpendentMinimal Support (needs reminders and/or minimal supervision)Moderate Support (Needs support with wiping and/or other bathroom needs)Maximum Support (needs to be changed during the day)
Specific sensory needs
Known triggers that could require increased support to maintain self-regulation
Level of support needed in community settings or during a field trip, lunch, or other activities*
Physical capabilities regarding walking and physical activity*
Additional accessibility or support considerations
Interests & Attendance
What hobbies or activities does the participant enjoy?
Which days would your family be interested in attending?*

MondayTuesdayWednesdayThursday
Camp fee note: $50.00/day to be paid weekly.
Financial Support Options
Scholarship or sponsorship preference*

YES (Scholarship application will be emailed. Applications open May 1, 2026.)NOI don’t need a scholarship but would like to sponsor someone in need.
If you selected YES, explain how a scholarship will be helpful for your family at this time.
Goals, Communications & Referral
What do you hope they will gain from this summer experience?
Would you like to receive our mailing list updates?*

YESNO
How did you hear about us?*

Facebook/Social MediaWebsiteFriendFlyer/Brochure/Print MarketingAnother ProgramOther
Signature*
Should be Empty:

Summer Program Registration Form

Participant & Guardian Information

Support Needs & Accessibility

Interests & Attendance

Financial Support Options

Goals, Communications & Referral