Nature-Based Adventure Camp

Nature-Based Adventure Camp - Fall

Please fill out form to reserve your spot.
Parent Guardian

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child's Name

First NameLast Name
Is your child or you currently a client?
Child's Birthdate

MonthDayYear
Date
How did you hear about this group

Other
Will you be using health insurance for this program? (Required)
Will you be using health insurance for this program?
If yes, please provide Insurance Company, Member ID (Optional) an Policy Holder's Name (if different):
If no, a member of our team will contact you to discuss self-pay options and determine whether you may qualify for our sliding scale program.
Questions? Please do not include sensitive or detailed personal or medical information in this message. This form is for general inquiries only. Our team will follow up with you directly.
I agree to receive communications by text message from the Children’s Home Counseling Services about my inquiry. You may opt-out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply.
Should be Empty:

Nature-Based Adventure Camp - Fall