Parent/Caregiver Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
MM
DD
YYYY
Child's Current Grade Level
Rising K
K
1st
2nd
3rd
4th
5th
What is your child's primary language? (If multilingual, please list all languages your child speaks at home).
*
Tell us about your child’s strengths.
*
What areas or challenges does your child need additional support in to thrive throughout their day?
*
Does your child have a formal diagnosis from a medical professional?
*
Yes
No
If yes, please describe:
Does your child have any allergies or dietary restrictions?
*
Yes
No
If yes, please specify:
Has your child successfully participated in a full-day drop-off program before?
*
Yes
No
Would your child be able to attend all 5 days of this camp?
*
Yes
No
Would your child have reliable transportation to be dropped off at 9:00am and picked up promptly by 4:00pm all 5 days of camp?
*
Yes
No
Please select your #1 preferred week:
*
Please select your #2 preferred week:
*
Is there anything else you would like us to know about your child to help us provide the best experience for them?
*
How did you hear about this program?
