Summer Camp Registration Form
Register your child for summer camp, select care options, and track discounts.
How many children are you registering?
*
Child's Full Name
*
First Name
Last Name
Child's Age
*
Child's Birthday
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
0
01
011
0111
01111
Year
Diagnosis
*
On the spectrum
Neurotypical
Do you require before or after care (drop-off earlier or later)?
*
Yes
No
Will your child need a provider to provide lunch, or will they come with their own lunch?
Provider will provide lunch
Child will bring own lunch
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which weeks will your child attend?
Week 1 (June 15-21)
Week 2 (June 22-28)
Week 3 (June 29-July 5)
Week 4 (July 6-12)
Week 5 (July 13-19)
Week 6 (July 20-26)
Week 7 (July 27-Aug 2)
Week 8 (Aug 3-9)
Week 9 (Aug 10)
Number of siblings signing up
Was a discount provided for sibling or multi-week sign-up?
Yes
No
Discount amount (USD)
Are you with the regional center?
Yes
No
Behavioral concerns (please describe any concerns we should be aware of)
Food allergies or other medical concerns (please list and describe)
Emergency Contact Name
Does your child have any medical conditions or special needs?
Parent/Guardian Address
*
Additional comments or special instructions
How did you hear about us?
Authorized pickup persons (names and relationship)
Payment method
Photo release consent
Yes
No
Consent and waiver accepted
Yes
No
T-shirt size
Preferred sessions or notes about sessions
Special accommodations requested
Refund policy acknowledgement
Does the child need a one-to-one aid?
*
Yes
No
Register
Should be Empty: