Summer Camp Jam 2017
Please provide the information below so that we can provide the best group possible for your child.
Child's Name
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Parent/Contact Name
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Phone
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Email
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Child's Date of Birth
MM
/
DD
/
YYYY
Special Need/Disability (music experiences will be adapted to meet these needs)
Your answer
Emergency contact during the Camp
Name, Relation and Phone #
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Location, Dates & Times
Seaside Center for Spiritual Living, 1613 Lake Drive, Encinitas, CA 92024
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Payment Options (please choose at least one)
How will you be paying?
You will be contacted for payment
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What size shirt does your child wear?
Each camper receives a Camp Jam T-shirt (Toddler size may not be available - will contact you if this is your preference)
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How did you hear about Camp Jam?
(please check one)
What rewards are motivating to your child? What prompts work best?
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What activities (sports, Karate, dance etc.) does your child/teen participate in?
Your answer
What favorite songs, artists, or music games/videos does your child enjoy?
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Does your child/teen have any medications or allergies? If so explain.
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Does your child have any behavior issues we should be aware of? If so, what approaches have been most successful?
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Has your child ever been in a social or music group before? If so, please share what program.
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Does your child need special assistance with communication? If so, please explain.
Your answer
To help your child be successful, is there anything else you would like us to know?
Your answer
I understand that the Camp Jam will only be held for 4 days. The price for my child's participation in the program is $325-Early Registration by 7/31/17 or $375-Late Registration after 7/31/17. By clicking the box below, I am aware that I will not receive a refund for any missed sessions/days. Payment is nonrefundable.
Please click the box below if you agree
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The Music Therapy Center of california may photograph and/or videotape during the camp for marketing or educational purposes. Marketing will be used for promoting therapy services designed to benefit families and children with special needs.
Please click one of the boxes below to indicate your preference:
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