Camp Chit Chat 2024
Applications are due April 15th
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Email *
What is your child's name? (First and last)
*
Child's Date of Birth *
MM
/
DD
/
YYYY
Parents' names (First and last) *
Home address *
City, Zip *
Cell number
Diagnosis *
Required
What languages are spoken in the home *
Required
What languages does your child speak? *
(For grant purposes only) What is your income level? *
Our foundation policy is that all children must be immunized to attend programs. Is your child fully immunized? DTap, Polio, HepB, Hib. A copy of their immunization form is required for attendance.
*
What school/programĀ 
does your child attend?
*
Does your child have an IEP and receive speech therapy services at school? *
If your child receives therapy services please list the type (speech, OT, ABA), provider (place/name) and how often (1x/week for 30 min). *
Required
What speech/language/social goals do you have for your child this summer? *
We have more than 60 children attending camp each week. We do our best to work with your schedule; however you may not get the time that you prefer, so please be flexible! List multiple times and days (at least three) that your child can attend a therapy session.
Mon
Tue
Wed
Thu
9:00am-10:00am
10:15am-11:15am
11:30am-12:30pm
1:30pm-2:30pm
If siblings or cousins are attending camp and you need the same time or back to back times, please list the other child's name so we can plan accordingly.
How did you hear about camp? *
Has your child attended Camp Chit Chat before? *
Will your child be receiving any other services (summer school, therapy) during the summer? *
What size shirt does your child wear?
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What is your child's ethnicity?
*
What happens next? You will receive an email from us that we received your application. We will also provide more detailed information about our program and who is enrolled. Thank you!
A copy of your responses will be emailed to the address you provided.
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