Camp Jam Winter Camp Registration 2017
Please provide the following information so that our counselors working with your child can get to know them prior to your desired camp start date:
Camper's First Name *
Your answer
Camper's Last Name *
Your answer
Parent/Guardian's Name *
Your answer
Daytime Phone *
Your answer
Emergency Contact during the Camp *
Your answer
Emergency Contact Phone Number *
Your answer
Email *
Your answer
Camper Date of Birth *
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School *
Your answer
Grade/Classroom *
Your answer
Please choose a day and location *
Required
Special Need/Disability* *
*Music experiences will be designed and adapted for each individual's needs.
Your answer
How did you hear about Camp Jam's Winter Camp? *
What rewards are motivating to your child/teen? What prompts work best? *
Your answer
What activities (sports, karate, dance etc.) does your child/teen participate in? *
Your answer
What favorite songs, artists, musical games or videos does your child/teen enjoy at home? *
Your answer
Does your child/teen have any medications or food allergies? If so, please explain. *
Your answer
Does your child/teen have any behavior issues we should be aware of? If so, what methods and approaches have been most successful? *
Your answer
Does your child/teen need special assistance with communication? If so, please explain. *
Your answer
In order to provide your child/teen with a successful experience is there anything else we should know?
Your answer
The Music Therapy Center of California may photograph and/or videotape during the camp for marketing or educational purposes. Marketing materials will be used for promoting therapy services designed to benefit families and children with special needs. Please check one of the boxes below to indicate your preference: *
Required
Payment options: By filling out this form, you acknowledge that registration for camp is $99 for 1 day and there are no refunds for missed attendance. Payment is due at time of registration! Some one will call you to set up payment based on your response below:
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