2025 Summer Camp Application

2025 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.

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

RETURNING CAMPERS and MIRIAM STUDENTS do NOT need to complete this application. Please email Gail Porter, gporter@miriamstl.org, with your selected camp(s)/session(s) to receive a registration link.

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

You must meet the following entrance criteria to attend camp. Please do NOT proceed with this application if any of the below pertains to the prospective camper:

requires 1:1 assistance with participating in activities, feeding, or toileting
has a paraprofessional during the school year
has toileting accidents
has significant behaviors including eloping and violent actions
learns at a slower pace due to significant cognitive delays
not able to communicate/verbalize at a sentence level

How did you hear about our camps?*

Child's Name*

First NameLast Name

Child's Gender*

Child's Birth Date*

Date

School attending this year 2024-25*

School attending next year 2025-26*

Grade will enter next year 2025-26*

Who is the child living with?*

Parent Name*

First NameLast Name

Parent Email*

example@example.com

Parent Phone Number*

Please enter a valid phone number.

Parent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Each camp session is three weeks

June Session: June 9-27, 2025 (no camp June 19)

July Session: July 7-25, 2025

I am interested in the following June session camps*

**FULL**Reading Skills Camp 8:00-11:00am $2000Social & Emotional Skills Camp 8:00-11:00am $1300**FULL**Writing Skills Camp (ONLY ENTERING GRADES 4-8) 8:00-11:00am $1300Social & Emotional Skills Camp 12:00-3:00pm $1300Executive Function & Study Skills Camp (ONLY ENTERING GRADES 4-8) 12:00-3:00pm $1300Ultimate Camp Experience (MUST BE COMBINED WITH A MORNING CAMP) 12:00-3:00pm $845Not interested in June session

I am interested in the following July session camps*

Social & Emotional Skills Camp 8:00-11:00am $1400**FULL**Reading Skills Camp 8:00-11:00am $2100**FULL**Executive Function & Study Skills Camp (ONLY ENTERING GRADES 4-8) 8:00-11:00am $1400**FULL**Social Skills Through Games Camp (ONLY ENTERING GRADES 4-8) 12:00-3:00pm $1200Social & Emotional Skills Camp 12:00-3:00pm $1400**FULL**Ultimate Camp Experience (MUST BE COMBINED WITH A MORNING CAMP) 12:00-3:00pm $900Not interested in July session

My child is applying for admission to Miriam School (K-8).*

YesNoMaybe

I am interested in being contacted about educational opportunities at Miriam, such as Miriam School (K-8) and/or Miriam High School (9-12).*

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?*

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 past three months?*

Does your child have any of the following Educational Service Plans (check all that apply)?*

IEPISP/IFSP504 PlanMy child does not have an educational plan

If my child has any of the above educational service plans, I understand that I will provide Miriam Camps with a copy of their current FULL plan.*

Yes

Has your child been given assessments to determine Cognitive (IQ) and/or Academic (Achievement) abilities? (Testing may also 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, they have been given these assessments.*

YesNo

If my child has undergone assessments to determine IQ or Academic Achievement, I understand that I will provide Miriam Camps with a copy of the FULL evaluation report.*

Yes

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

List one or two goals for your child to work towards in camp.*

Please describe your child's relationship with adults.*

Please describe your child's relationship with other children.*

Please describe any unusual behaviors, habits, and/or fears that your child exhibits. If not applicable, write "none".*

Please describe any serious illnesses/medical conditions, including age that illness occurred. Also list current medications. If not applicable, write "none".*

Educational information 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 - Cognitive, Academic, Speech/Lang, etc. 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: Jami Millman jmillman@miriamstl.org

OR

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

OR

Mail to : Miriam Summer Camps, 501 Bacon Ave, 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, and medical records, as well as opinions with the below listed teachers*

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 below from your child's current school who are familiar with your child's daily routine/performance. This is required information.

Child's Name*

First NameLast Name

Child's Date of Birth*

Date

Name of Contact 1*

Position*

Name of school*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Name of contact 2*

Position*

Name of school*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Application for admission is considered without regard to race, sex, age, religion, or ethnic group.

Date submitted*

Date