Jam Club Camp 2018 Registration
Last Name *
Your answer
Student First Name *
Your answer
Student Birthdate *
mm/dd/yyyy
Your answer
School *
Your answer
Grade in fall 2017 *
Your answer
Primary Special Needs Diagnosis *
Your answer
What kind of help does your student need to complete a task? *
Please describe your students' attention span
If your student requires one to one assistance, will you or an assistant be joining us for camp? *
It is OK if you or an assistant cannot attend camp with your student. We are asking this question to make sure that we have enough helpers so that your student is successful at camp.
Describe your student's mobility *
What is the smallest thing on this list that your student can grip independently? *
Approximate. Please don't take the time to find all of these things and test your student!
How does your student express happiness? *
Check all that apply
Required
How does your student express displeasure or pain? *
Please check all that apply
Required
Parent Last Name *
Your answer
Parent First Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Home phone number *
Your answer
Parent Cell Phone number *
Your answer
Best email to reach you *
Your answer
Student Email
Your answer
T-shirt size *
Camp shirt is included in camp tuition. No size adjustments may be made after the first day of camp
Camp payment method *
To pay online, please return to our camp page. Our mailing address is also listed on our website.
Anything else we need to know about your student?
Your answer
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