2026 Fall Friends Camp
Basic Information
Your Name
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First Name
Last Name
Child's Name
*
First Name
Last Name
Child's Birthday
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Can we send text messages to the phone number listed above?
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Yes
No
Email
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example@example.com
How did you hear about our camps?
I heard from:
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Word of Mouth
Previous/Current Patient
Preschool Screener
Google
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Physician
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Insurance
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How does your child currently communicate?
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Full sentences
2-3 word phrases
Single words
Speech generating device (e.g. TouchChat, LAMP, Proloquo)
Other
Does your child receive private speech and language services?
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Yes
No
Name of facility where speech and language services are provided
Does your child receive ABA services?
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Yes
No
Name of facility where ABA services provided
To help us create the best group experience for your child, please check any behaviors that would be helpful for us to consider.
May engage in physical behaviors toward self or others (e.g., hitting, pushing, biting) when frustrated/upset
May have difficulty regulating emotions when frustrated/upset
May leave the group area without telling an adult
Does your child have any medical diagnoses?
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Yes
No
If so, what are the medical diagnoses?
Is your child potty trained? If your child is not potty trained, parent will need to be easily contacted for a diaper change during group sessions.
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Yes
No
Does your child have any food allergies or sensitivities?
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Yes
No
If so, please be specific in regard to allergies and/or sensitivities.
Is there any additional information that would be beneficial for us to know?
MJ Kidz LLC Photo and Video Release
Please designate and sign.
I grant MJ Kidz LLC and any designated collaboration partners permission to photograph and/or record video of the participants named on this form for use in marketing, social media, promotional, and educational materials. I understand that content may be shared across digital and print platforms and that this release has no expiration date unless revoked in writing. MJ Kidz LLC retains the right to use approved content at its discretion, in a manner consistent with the organization's values and mission.
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I agree to the above
I do not agree to the above
Signature
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Payment Agreement
All groups are supported by a Speech and Language Pathologist. Please note that space is limited for each group session. Once registered and contacted by our billing department, payment must be made within 3 business days to secure your spot.
Would you prefer to receive requests for payment via email or text message?
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Email
Text
Signature
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Fall Friends Camp Marlton
This group will focus on language and socialization skills with peers for children ages 5-9.
Select Day(s)
Marlton Location: Thursday, November 5th, 9:00am-12:00pm
Marlton Location: Friday, November 6th, 9:00am-12:00pm
Both
Fall Friends Camp Collingswood
This group will focus on language and socialization skills with peers for children ages 5-9.
Select Day(s)
Collingswood Location: Thursday, November 5th, 9:00am-12:00pm
Collingswood Location: Friday, November 6th, 9:00am-12:00pm
Both
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