Special Needs Summer Camp Registration Form
Child's Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Grade Level In School
T-shirt size
XS
S
M
L
XL
XXL
XXXL
Shirt Color
Height
Weight
Age Group
Group 1 (1-4 Yrs Old) 5-Days Camp Program
Group 2 (5-9 Yrs old) 10-Days Camp Program
Group 3 (10-16 yrs old) 15-Days Camp Program
Does your child can go to the bathroom without help?
Yes
No
Bathroom assistance?
Need assistance all the time
Assistance only if needed
Zero Bathroom assistance
Any known allergies?
Other medical conditions?
Fears and dislikes?
Can he/she follow simple instructions?
Yes
No
What instructions can he/she follow?
Verbal
Written
Gestures
Picture (Visual aid)
Other
Does your child need feeding instructions/restrictions/special diet?
Yes
No
If yes, please provide us with detailed explanation
Is he/she aggressive?
Yes
No
Do you have any behavioral plan or instructions?
Parent or Guardian Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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