Feeding Camp Sign Up Questionnaire
Our Feeding Camp is a weekly Friday program that helps children build a positive relationship with food. Each session builds on the last, supporting progress with picky eating through guided food exploration, exposure to new textures and food groups, and play-based strategies in a low-pressure environment. Families receive a take-home toolkit and resources each week to support continued progress at home. Please fill out this form to register your child for the Feeding Camp and provide necessary background information.
Parent/Guardian's Full Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
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First Name
Last Name
Please select the main feeding challenges your child currently experiences (Check all that apply):
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Picky eating (e.g., restricted variety of foods)
Refusal to try new foods
Difficulty with specific textures/consistency
Gagging or vomiting related to food/textures
Excessive time taken for meals (e.g., over 30 minutes)
Choking/Swallowing difficulties (Dysphagia)
Behavioral issues during mealtimes (e.g., tantrums, leaving the table)
Reliance on tube feeding or supplemental nutrition
Difficulty drinking from a cup/straw
Does your child have any known food allergies or dietary restrictions? If yes, please specify.
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What group would your child be apart of?
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Ages 1-4 Session (9:30 AM - 10:30 AM)
Ages 5-8 Session (11:00 AM - 12:00 PM)
What are your child's current eating habits?
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Does your child self-feed (utensils or hands)?
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Parent/Guardian's Full Name
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Submit
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