Camp Registration
This form is for those requesting a spot in one of our upcoming Summer Camps. Completing this form does not guarantee you a spot in the camp. Submissions will be reviewed and approved in the order they are received within 24-48 hours.
Select One:
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Please Select
Sun + Sand (girls 2nd-5th grade)
Wild + Wander (boys 2nd-5th grade)
Middle School Bootcamp (emerging middle school girls)
I am requesting a spot in a camp for: (child's name)
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First Name
Last Name
Contact 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 Age:
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Date of Birth:
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-
Month
-
Day
Year
Date
Grade Level Entering (Aug 2024):
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Allergies:
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Please list any specific concerns around client's mental health or ability to mange emotions:
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What do you hope to get out of this camp?
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Is the registering client a current or past patient of HeartLife?
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Yes
No
Who was/is the treating therapist?
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Are you comfortable signing a release for us to speak with this therapist?
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Yes
No
Parent Information
Parent #1 Name
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First Name
Last Name
Parent #1 Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Parent #1 Email
*
example@example.com
Parent #2 Name
First Name
Last Name
Parent #2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent #2 Email
example@example.com
Marital Status: (If joint custody, we will require both parties' contact info and consent to treat.)
Married
Separated
Divorced, joint custody
Divorced, one has decision-making authority
Widowed
Emergency Contacts
Emergency Contact #1
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2
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Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Payment is due on the first day of the camp. By signing below, you agree to pay for the camp in full at the start OR you agree to contact the front desk if accommodations must be made prior to camp beginning.
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Submit
Should be Empty: