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ABA Connection Summer Camp Registration
Please use this form to submit your interest in attending the ABA Connection Summer Camp.
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Email
*
Your email
Summer Camp, Closed for Memorial Day (May 29th)
Today's Date
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Client Information
Participant's Name:
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Full Name
Your answer
Date of Birth
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Household Information
Parent/Guardian Name (Primary Contact)
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Your answer
Relation
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Your answer
Cell Phone:
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Your answer
Street Address (if different)
Your answer
First Date for Summer Camp
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End Date for Summer Camp
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YYYY
Emergency Contact Name
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Your answer
Emergency Contact Relation
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Your answer
Emergency Contact Phone Number
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Your answer
Additional Information
Do you currently receive ABA Services from ABA Connection?
Yes
No
Interested
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Dietary Need/ Food Allergies
Your answer
Environmental Allergies
Your answer
Other Concerns (ex: behavioral, peer interactions, toileting)
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Your answer
How many hours are you interested in per week?
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Your answer
Are there any consistent days the client will NOT be attending?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Required
How did you hear about us? If referred by an ABA Connection employee, please write their name here.
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Your answer
Permission to Photograph
Photographs taken while at camp may be used used in social media posts or in printed publications.
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Yes
No
Permission to Treat
The Person this registration is for has permission to engage in all camp activities except as noted. I hereby give my permission to ABA Connection to provide routine first aid/health care, oversee self-administration of any medications provided by caregiver, and seek emergency medical treatment. I agree to the release of any records necessary for insurance purposes if receiving ABA Therapy. In the event that I or the emergency contact cannot be reached in an emergency I hereby give permission to ABA Connection to secure and administer treatment, including hospitalization, for the person named in this form. This completed registration form may be printed/copied as needed.
Type your full name below to confirm your acceptance of the above Authorization and Acknowledgements statement
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Your answer
Billing Information
Camp Fees are $175/week which covers 40 hours per week of camp attendance. Camp fees are non-refundable and are due at least 1 week in advance. Camp fees will cover arts & crafts, trained behavioral staff, and additional materials/activities.
Camp Fees may be paid electronically through PayPal. Payment plans are available.
$175/week
Full Summer: $1750 (10 weeks)
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Pay via PayPal
For More Information
Contact the ABA Connection Office at
Phone: (904) 201-9129
Email: referrals@abaconnection.com
Address: 175 Cumberland Park Dr, Ste 100, St. Augustine, FL 32095
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