#UtahCNR Application 2018
Participant First & Last Name *
Your answer
Parent/Guardian First and Last Name *
Your answer
Participant Date of Birth *
Please enter in MM/DD/YYYY format.
Your answer
Parent/Guardian Primary Phone Number *
Please enter in ten-digit format: (801) 555-5555
Your answer
Parent/Guardian Secondary Phone Number
Please enter in ten-digit format: (801) 555-5555
Your answer
Parent/Guardian Mailing Address *
Your answer
Parent/Guardian Email Address *
Your answer
How did you hear about Camp Neuro Revolution? *
Your answer
What is the level of participation we can expect from your child? *
This helps staff, at CNR, to know how to best prepare for and accomodate your child and their needs.
Tell us how we can best assist and guide your child, if necessary.
Your answer
Do you have any concerns with your child staying overnight at Camp? Please explain.
Your answer
If your child is unable to stay overnight, are you willing to transport them to and from the National Ability Center for the duration of Camp?
Please note, the Epilepsy Association of Utah and Camp Neuro Revolution are not responsible for costs of transportation or lodging outside of the National Ability Center.
Your answer
If your child needs 24 hour assistance, are you willing to stay with them during the day and transport them at night?
Your answer
Critical Information *
Camp Neuro Revolution (CNR) starts on the afternoon of Wednesday, June 18th and ends on the early afternoon of Thursday, June 21, 2018. CNR is located at the National Ability Center (NAC) in Park City, Utah. Please make note of this information. It is required that parents/guardians check their child in at the NAC on 6/18/18 and pick up their child on 6/21/18 at the NAC, unless other arrangements are made with the Director. Prepare to make any necessary accommodations. Upon an applicants acceptance registration forms are provided, which are due by 6/8/18 . Also, upon an applicants acceptance, a $50 registration fee is required. While the cost of camp is $450, scholarships are available, based upon need. Payment of registration fee and any other donation is due by 6/15/18. Please indicate below that you understand the listed expectations on transportation, fees, scholarships and time of duration for your participant.
Any Comments, Questions, Concerns? *
Please utilize this space to voice any concerns you may have, or may want to bring to the Director's attention. Otherwise, make note of the following information and feel free to email the EAU's Executive Director, Nicole Young, at info@epilepsyut.org, if you need any other information. Remember, this form is not considered full registration for your child. The application is due by May 11, 2018. You will be notified, via email, within the last week of May about the status for your child's application. Please note, if your application is not received by midnight on May 11, 2018, your child's application may not be accepted.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.