Innovative Summer Camp Sign-up Form
*Please keep in mind that completing this form DOES NOT guarantee registration, space is first come first serve, an invoice will be sent and must be paid in order to reserve your spot*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Name #2
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contacts
*
Please list name, relationship, and phone number
Authorized Pick Up List
*
List the names of anyone, other than those listed above, who may pick up your camper
Camper's Name
*
First Name
Last Name
Nickname
Camper's Date of Birth
*
/
Month
/
Day
Year
Date
Please list any allergies we should be aware of
*
Any medical conditions that would be helpful to know?
*
Does the camper receive any therapy? If so, please select below
*
ABA
Speech/ Language
Occupational
Counseling
None
Other
Which best describes the camper's communication style?
*
Speaks in full sentences and has conversations that sound the same age as their peers.
Uses phrases and sentences but continued back-and-forth exchanges can be challenging.
Uses mainly one word or short phrases
Uses an alternative mode of communication (photos, gestures, etc.)
Has very limited communication skills
Is there anything else you would like us to know regarding your camper's social/ communication skills?
List any accommodations the camper receives in the classroom that would be helpful in a camp setting.
Can your camper take care of their personal hygiene needs independently?
*
Yes
No
If no, please explain
Choose which best describes the camper
*
Rows
Has Never Happened
Happens Occassionally
Happens Monthly
Happens Weekly
Aggression towards adults or children
Self-injurious behavior
Running with a disregard for safety
Property Destruction
Running away within the classroom/building
Eating non-food items
Which weeks would you like to attend camp? Choose all that apply
*
6/29-7/3 (ages 5-17)
7/6-7/10 (ages 5-17)
7/13-7/17 (ages 18-25)
7/20-7/24 (ages 18-25)
Submit
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