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Child's Name *

First Name

Last Name

Parent's Name *

First Name

Last Name

Date

MM

DD

YYYY

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Date *

MM

DD

YYYY

Their Birthdate *

MM

DD

YYYY

Does your child have a 504 or IEP at his/her school? *

Yes

No

If your child has an IEP or 504 at school, would you be willing to share important topics of the document with us? *

Yes

No

Have there been any recent changes in your family dynamics (divorce, separation, death of loved one, etc.)? *

Yes

No

Have there been any impactful events in your child’s life in the past year (change of home or school, etc.)?

Yes

No

Does your child have any emotional or behavioral challenges (homesickness, anxiety, socialization challenges, etc.) that we can help to manage in the camp setting? *

Yes

No

Does your child have any physical issues that we will need to know about during his/her stay at camp? *

Yes

No