Waiting List Application Form

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The health and safety of our campers are our top priority. It is essential that parents/guardians provide our staff with accurate and up to date information about their camper, so we can best meet their needs while at camp.

Child's First and Last Name *

Age *

Gender *

Parent's Names *

Email *

Phone Number *

Mailing Address *

Date *

YYYY

Does a sibling already attend camp? *

Yes

What school district is your child attending currently? *

Current School Attending *

Current Grade Level *

Areas of Disability *

Please check all that apply: (To qualify for camp, individual must have at least one) *

IEP

Behavior Plan

504 Plan

Required

Is behavior being addressed in your child's IEP or 504? *

Yes

Not sure

Primary Goal *

Social Skills: communication, active listening, emotional regulation, teamwork

Daily Living Skills: communication, personal care, functional life skills, independence, job skills

Does your child have ongoing medical needs that require the close supervision of a physician? If yes, please explain. *

Does your child use any medical equipment? *

Mobility device/orthosis

G-tube/PEG tube

Respiratory equipment

Other:

Does your child require a care plan for seizures, asthma, or allergies? *

In 250 words or less, please provide a brief description of your child's strengths and needs (i.e. verbal/nonverbal, toilet trained, socially motivated, eats with assistance). Include any specific concerns you may have (communication, behavior, or other). *

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