Child's Legal Name

Date of Birth

Parent / Legal Guardian

Address

Phone Number

Email Address

Please list relevant diagnosis/diagnoses

Please list any specialized equipment that your child will use during the group (example: walker, etc)

Please list any conditions which may require immediate medical assistance (example: diabetes, epilepsy, bee sting allergies, food allergies, etc)

Please list any concerns you currently have relating to developmental skills

Please list any specific functional goals that you would like your child to focus on during camp

Please list 3 things that you feel your child does well

Please share any other information you feel would be helpful for our staff while working with your child

If your child has specific needs that require one-on-one assistance at all times, are you (parent) able to remain for the duration of the group if needed?
YesNo

Which group are you registering your child for?
Nature Play - Tuesdays/Thursdays (June 6 - July 18) - 9:00-11:00
- Basic Group Package - $800
- Additional Resources Package - $900 - includes online access to weekly schedules / activities and pictures from group sessions, a 20 minute weekly follow-up phone call, and recommendations regarding carry-over of activities into the home.

Signature (First and last name):

Relationship to child: