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Social Skills Camp Registration Form
June 11-15, 2018 9-12pm
For multiple children please submit a separate form for each.
13720 Midway Rd. Suite 106 Dallas, Texas 75244
469-203-1533 |
morganclairemyers@gmail.com
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Email
*
Your email
Child Name
*
Your answer
Child's Birthdate
*
MM
/
DD
/
YYYY
Age
*
Your answer
*
Male
Female
Current Treating Therapist if any
Your answer
Special Instructions
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How did you hear about us?
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Parent Name:
*
Your answer
Address
*
Your answer
Parent Phone number
*
Your answer
Email
*
Your answer
Emergency Contact: Name and Phone Number
*
Your answer
Food restrictions/Diet needs:
*
Your answer
I understand the camp fee is $250 and is due at intake or first session. This includes all supplies needed to facilitate camp.
*
Yes
Required
I authorize my child to attend camp with a therapist at Hope Child & Family Center of Texas. Please initial.
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