Camp D.I.C.E. Summer 2020 Application
June 15- Aug 7, 2020
100 Beatties Ford Road Charlotte NC 28216 (JCSU)
Perry Science Building
Email address *
Campers Name *
Your answer
Campers Age *
Your answer
Campers DOB *
Your answer
Campers Sex *
Campers Shirt Size *
Required
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Diagnosis *
Your answer
Allergies *
Your answer
Medications *
Your answer
Hobbies & Interests *
Your answer
ARE ASSISTIVE TECHNOLOGY OR DEVICES USED? (EX. WHEELCHAIR, TALK BOX, ETC.) *
Required
LEVEL OF SELF CARE (1-Independent - 5-Needs Assistance) *
Toileting assistance needed *
Required
Parents/Guardian Name *
Your answer
Phone number *
Your answer
What weeks will you attend? Please indicate if they will be full or half days. *
Required
Dietary restrictions *
EMERGENCY CONTACT INFORMATION #1 (Name, Relationship, & Phone number) *
Your answer
EMERGENCY CONTACT INFORMATION #2 (Name, Relationship, & Phone number) *
Your answer
PREFERRED HOSPITAL IN CASE OF EMERGENCY *
Your answer
NAME OF INSURANCE *
Your answer
DOES YOUR CHILD RECEIVE PRIVATE THERAPEUTIC SERVICES? *
Please explain what type of therapy: *
Your answer
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