Summer 2023 Enrollment – 2nd – 5th Grade

Child's Information

Child's Name*

Date of Birth:*

T-Shirt Size*

Youth XS

Youth S

Youth M

Youth L

Adult S

Adult M

Adult L

Adult XL

Adult XXL

Grade Completed*

School

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Parent 1 Information

Parent 1 Name*

Parent 1 Email*

Parent 1 Phone*

Best time to call

Address*

Parent 2 Information

Parent 2 Name

Parent 2 Email

Parent 2 Phone

Best time to call

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Relationship to Child*

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Referred by

Friends we know coming to camp

Friend Name

Relationship to Friend

Child's Medical Information

Allergies (Please List)

Providers we are currently working with

Current Medications/dosage/frequency

Medication at Camp*

Yes

If yes, please list medication, dosage, and when and how to give. *Medication must be in original container in Ziplock baggie with child's name on the baggie and given to teacher*

Is there anything medically we need to know about your child that could effect their time here at camp? (sensitive to heat, kidney disease, etc)

Current Diagnosis and or medical condition(s)

(Continued)

My child does not have a current diagnosis and/or medical condition

Child's Behavioral Information

Likes*

Supports that maybe helpful (visuals, time, space, demonstration, etc.)*

My child needs support with:

Social behaviors ( personal space/greetings/goodbyes)

Conversational skills

Making/keeping friends and getting along (social rules/initiating/problem solving)

Emotional Regulation (labeling emotions/understanding emotions of him/herself and those of others/relaxation techniques during times of frustration or times of stress)

Other:

Please specify:

Supports that may be helpful for my child:

Triggers for my child or Behaviors noted at home/school

What goals do you have for camp?

Select Camp Date(s)

June 19-23 (9am – 4pm) | 2nd - 5th Grade *WAIT LIST ONLY*

June 26-30 (9am – 4pm) | 2nd - 5th Grade

July 10-14 (9am – 4pm) | 2nd - 5th Grade

July 17-21 (9am – 4pm) | 2nd - 5th Grade

July 24-28 (9am – 4pm) | 2nd - 5th Grade *WAIT LIST ONLY*

August 7-11 (9am – 4pm) | 2nd - 5th Grade

August 14-18 (9am – 4pm) | 2nd - 5th Grade

Select Social Skill Group

June 12 - August 18 (4th of July off) | Wednesdays 5pm - 7pm | 2nd - 5th grade

Select Farm Saturdays Date(s)

June 17 | 9am - 1pm | 2nd - 5th Grade

June 24 | 9am - 1pm | 2nd - 5th Grade

July 15 | 9am - 1pm | 2nd - 5th Grade

July 22 | 9am - 1pm | 2nd - 5th Grade

Payment Details (Please make sure that your selected options above corresponds with the correct deposit(s) below) EXAMPLE Clicking 3 separate weeks of camp would correspond with "3 Weeks of Summer Camp Registration Deposit" below

1 Week of Summer Camp Registration Deposit

2 Weeks of Summer Camp Registration Deposit

3 Weeks of Summer Camp Registration Deposit

4 Weeks of Summer Camp Registration Deposit

5 Weeks of Summer Camp Registration Deposit

6 Weeks of Summer Camp Registration Deposit

7 Weeks of Summer Camp Registration Deposit

Summer Social Skills Deposit

1 Days of Farm Saturdays Deposit

2 Days of Farm Saturdays Deposit

3 Days of Farm Saturdays Deposit

4 Days of Farm Saturdays Deposit

Total $ 0

Credit/Debit Card

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