Clone of Nurest Teen Summer Camp Registration [Final]

Camper's Full Name

First NameLast Name

Date of Birth

Date

Gender

Other

Pronouns

Other

Primary language(s)

Grade and School

Parent/Guardian Full Name

First NameLast Name

Parent/Guardian Email Address

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Full Name

First NameLast Name

Parent/Guardian Email Address

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please list all individuals authorized to pick up your teen from camp (in addition to the parent/guardian listed above). Include their full name, relationship to camper, and phone number.

Does the camper have any allergies, diagnoses, glasses, or medical conditions? If yes, please specify.

Please list any medications the camper will need during camp.

How does your child communicate?

Other

Which of the following daily living skills can your child perform independently? (Select all that apply)

Please describe any support needed for the daily living skills checked above.

What are your child's sensory preferences and sensitivities? How do they handle sound, touch, clothing textures, food textures, lights, movement, etc.?

Does your child have an interest in connecting with peers? What are their social strengths and areas where support may help?

Examples: Sharing, turn-taking, flexibility, accepting others' ideas, sharing their own ideas, self-advocacy, etc.

Does your child have any behaviours or responses we should know about, such as meltdowns, shutdowns, other stress responses?

What are some common triggers or stressful situations your child encounters?

Are there any safety concerns we should be aware of?

Examples: Self-injurious behaviours, aggression, elopement, or other concerns.

Are there any challenges with transitions or changes in routines?

What are your child's interests, strengths and skills, personality, and motivators?

*Motivators: What helps your teen feel engaged, comfortable, or encouraged?

What is the home and family structure of your child? Do they have any siblings or important family members?

Are there any cultural, language, or family considerations we should be aware of?

Has your child undergone previous therapies, supports, or assessments? If so, explain.

What are your child's interests and preferred activities?

What are your goals for the summer (Example: social skills, independence, routine, or academics)?

Examples: Social skills, independence, routine, academics, etc.,

Select your preferred camp session(s).

Our camp is overseen by a BCBA.

Camp fees may be eligible for coverage through OAP funding.

The cost is $900 per week for 4-6 year olds, and $820 a week for 7-10 year olds. This cost covers all activities and outings for the week.

A $100 deposit is due at registration to secure each week, and the remaining balance is due the month before your camp week.

Payments can be sent to admin@nurestcenter.ca

Please note: A non-refundable registration fee of $100 is required to reserve your spot. The remaining balance will be invoiced and must be paid in full one month before the start date of camp. For financing options, please contact admin@nurestcenter.ca.

Please indicate any special needs, accommodations, or additional information we should know that would help us support your child in a positive and safe way.

Medical Consent

Consent to Exchange Information

I authorize Nurest Treatment Center staff to consult and exchange relevant information (e.g., reports, assessments, and progress updates) about my child with other professionals or agencies involved in their care, such as their physician, school, speech-language pathologist, or occupational therapist, for the purpose of coordinating treatment and planning the camp program. I understand that this consent is required for the release of confidential health information.

Consent to Take Photos

I authorize Nurest Treatment Center staff to take photographs and videos of my teen during program activities. I understand these materials may be used for internal documentation, sharing progress updates with families and for marketing or promotional purposes (e.g., website, social media, brochures). I can choose to opt-out of specific uses by contacting the center.

Liability Acknowledgement

By signing below, I confirm that all information provided in this registration form is accurate and complete to the best of my knowledge.

Signature