2023 Summer Camp Application

2023 Summer Camp New Camper Application

Thank you for your interest in Miriam Summer Camps! Please submit this form indicating which camp(s) you are considering, along with the required documentation outlined below. This application is required for placement consideration in Miriam summer camps. RETURNING CAMPERS and MIRIAM STUDENTS do not need to complete this form and should contact Gail Porter (gporter@miriamstl.org) to request the camp(s) of your choice.

Submission of the application is not a guarantee of camp acceptance.

Feel free to contact us at 314-961-1500 with any questions regarding this process.

Click here to view 2023 Summer Camp brochure
How did you hear about our camps?*
Child's Name*

First NameLast Name
Child's Gender*
Child's Birth Date*

MonthDayYear
School attended in 2022-23*
School will attend in 2023-24*
Grade will enter in 2023-24*
With whom is child living?*
Parent Name*

First NameLast Name
Parent E-mail*
Parent Phone Number*

Area CodePhone Number
Parent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeUSA
Session 1: June 20-30, 2023 (no camp June 19)

Session 2: July 3-14, 2023 (no camp July 4)

Session 3: July 17-28, 2023

High School Mini Session: June 12-16, 2023
I am interested in the following session(s)*

**FULL**Academic Bootcamp Session 1: $1260 8:00-11:00am**FULL**SS Through Sports Camp Session 1: $1080 8:00-11:00amReading Skills Camp Session 1: $1080 12:00-3:00pm**FULL**SS Development Camp Session 1: $1080 12:00-3:00pmAcademic Bootcamp Session 2: $1260 8:00-11:00amSS Through Sports Camp Session 2: $1080 8:00-11:00amWriting Skills Camp Session 2: $1080 12:00-3:00pmSS Development Camp Session 2: $1080 12:00-3:00pmExec Function & Study Skills Camp (only grades 4-8) Session 2: $1080 12:00-3:00pm**FULL**Academic Bootcamp Session 3: $1400 8:00-11:00amSS Through Sports Session 3: $1200 8:00-11:00am**FULL**Reading Skills Camp Session 3: $1200 12:00-3:00pmSS Development Camp Session 3: $1200 12:00-3:00pmExec Function & Study Skills Camp (only grades 4-8) Session 3: $1200 12:00-3:00pmHigh School Social Teen Mini Camp (only grades 9-12) June 12-16: $600 12:00-3:00pm
My child is applying for admission to Miriam School/Academy for the 2023-24 school year.*

YesNoMaybe
I am interested in being contacted about other educational opportunities at Miriam, such as Miriam School (K-8th Grade) and/or Miriam Academy (9-12th Grade)*

YesNo
If you answered yes to the above question, do you give permission for the information provided in your camp application (including educational, mental health, or medical documents) to be shared with Miriam School and/or Miriam Academy?*

YesNoNot interested in being contacted
Is your child toilet trained and able to care for his/her toileting needs independently?*

YesNo
How many toileting accidents has your child had in the last 3 months?*
Please describe any bowel/bladder issues, assistance needs, etc. If no issues, write 'none'.*
Does your child have any of the following Educational Service Plans? Check those that apply.*

IEPISP / IFSP504 PlanMy child does not have an educational service plan
If my child has any of the above educational service plans, I understand that I will provide Miriam Learning Center with a copy of his/her current FULL plan.*

Yes
Has your child been given assessments to determine Cognitive (IQ) and/or Academic (Achievement) abilities? (Testing may also have been conducted in the areas of motor/sensory, speech/language, social/emotional, etc.). These may have been administered through the School District or through a private testing facility. If your child has an educational service plan through your school district, he/she has been given these assessments.*

YesNo
If my child has undergone assessments to determine IQ or Academic Achievement, I understand that I will provide Miriam Learning Center with a copy of the FULL evaluation report. This may be obtained through your school district, private/parochial school, Special School District or the private testing facility.*

Yes
My child receives the following special education services (check all that apply)*

NoneSelf-contained classroomResource roomGeneral education classroomOT/PT/Speech-LanguagePara/Shadow/Behavior AidOther (describe below)
Other special education services
List 1 or 2 goals for your child to work towards in camp.*
Please describe your child's relationship with adults.*
Please describe your child's relationships with other children.*
Please describe any unusual behaviors, habits, and/or fears that your child exhibits.*
Please describe serious illnesses/medical conditions - include age that illness occurred. List medications /dosages here.*
Educational info is required for ALL children being considered for camp acceptance.

For children who have Educational Service Plans, please send us:

1) A copy of the FULL Evaluation Report that determined the service plan, AND

2) A copy of the FULL Service Plan - IEP, ISP, IFSP, 504, etc. (whichever applies)

For children who do not have any of the above service plans, please send us:

1) Report Cards or Progress Reports, AND

2) Standardized test scores

Please send the required documents listed above in one of the following ways:

Email Rebecca Young: ryoung.camp@miriamstl.org

OR

Fax to: 314-968-7338 Please write "Miriam Summer Camps" on the fax cover sheet

OR

Mail to: Miriam Summer Camps

501 Bacon Avenue

St. Louis, MO 63119
Authorization to Release/Receive Confidential Information

I understand that by completing the information below and submitting this form, I am giving permission to release/receive the designated confidential information for one year from the date of my electronic signature. I understand that I may withdraw this permission at any time during the period by stating the request in writing.

ALL INFORMATION WILL BE KEPT CONFIDENTIAL AND USED SOLELY FOR ADMISSION PURPOSES
I hereby authorize Miriam and my school to obtain/release information regarding my child including personal, educational, social, psychological, psychiatric, medical records, and opinions with the below listed people.*

Yes
Electronic Signature of Parent/Guardian*
Information from teacher questionnaires will also be used to determine camp appropriateness and placement. Please list 2 TEACHER CONTACTS from your child's current school who are most familiar with your child's daily routine/performance. This is required information.
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Name of contact 1*
Position*
Name of school*
E-mail*
Phone Number*

Area CodePhone Number
Name of contact 2*
Position*
Name of school*
E-mail*
Phone Number*

Area CodePhone Number
Application for admission is considered without regard to race, sex, age, religion, or ethnic origin.
Enter the message as it's shown*
Date Submitted*

MonthDayYear
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