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Help us make this the best camp experience you have ever had! Please make sure to fill out all of the information completely. We look forward to seeing you at camp!
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Child's Last Name: *
Child's First Name: *
Address: *
Address: *
Address: *
Address: *
Diagnosis *
Please be as specific as possible. We will use this for the invoices you can submit to insurance.
Other health concerns/conditions *
Any allergies, medications, or pertinent medical history should be entered here. If none, please state "None".
Parent's Last Name *
Parent's First Name: *
Email: *
You will receive your camp packet and info via email. We prefer a frequently checked email address.
Phone: *
The best one to reach you, please.
Emergency Contact Name: *
Emergency Contact Phone: *
Date of Birth: *
School: *
Grade child will be entering: *
Pediatrician's Name *
Pediatrician's Phone Number *
Dentist's Name *
Dentist's Phone Number *
Preferred Hospital *
Insurance Company *
Insurance Policy Number *
Child's likes: *
Child's Dislikes *
Child's Strengths *
Child's Concerns: *
Goals for Camp *
My child receives the following therapies. *
Please provide therapists information
Name, Company, Email, Phone number
I hereby certify the minor is my son/daughter and that his/her date of birth is noted above. I do hereby certify that to the best of my knowledge and belief, said minor is in good health. I understand the policies as stated on the form. I understand the risks to my child in participating in activities, particularly physical activity. I take responsibility for the risks and agree to indemnify and hold harmless Upwards Pediatric Therapy, Elizabeth L. Tynan, MSPT LLC, Heather Edwards, OTR/L LLC and their officers, the Town of Fairfield, and the staff in the event my child sustains an injury. Program fees are non-refundable. *
Parent should please review the above release and type your name below. By typing your name you are providing an electronic signature.
In care of illness or accident, permission is granted for emergency treatment to be administered. It is further understood that the undersigned will assume full responsibility for any such action, including payment of costs. I hereby advise that the above named minor does not have any allergies, medicine reactions or unusual physical conditions that are not stated above. *
Parents should please review the above release and type name below
Photos and Videos are taken during programs for use of slide shows, scrap books, social stories, grant applications, trainings, publicity and marketing. If you do not want photos taken, please initial here. *
Please review and type name below
I understand that a prescription from my child's doctor for physical and occupational therapy is necessary in order to participate in Boot Camp. I will provide such prescription on or before the first day of camp. *
Please review and type name below
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