Super Kids Saturday Workshop
Workshop Dates:January 6th- February 3rd
Workshop Address: 642 Eagle Rock Ave. Suite 2 . West Orange, NJ, 07052
Contact us at: Info@njcchs.org


Email address *
Name of Super Kid (first / middle initial / last) *
Your answer
Grade *
Your answer
Birth Date *
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DD
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YYYY
Age *
Your answer
Gender *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Child Home Phone *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Home Phone *
Your answer
Parent/Guardian Work Phone *
Your answer
Parent/Guardian Cell Phone *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian Contact Preference *
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Relationship to Camper *
Your answer
Primary Physician Name *
Your answer
Primary Physician Phone *
Your answer
Primary Physician Address *
Your answer
Dietary restrictions *
Please list any allergies your child has *
Your answer
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. *
Required
What are your child's super powers? (child's strengths and interests) *
Your answer
What's your child's kryptonite? (child's challenges) *
Your answer
Please describe the situations in which your child is socially successful. *
Your answer
Please describe your child's social challenges. Please note, if your child is diagnosed with a specific developmental disorder, you do not need to describe symptoms of that disorder. Instead, please describe areas of social interaction that are particularly challenging for your child *
Your answer
Has your child ever had a play date? If so, does your child initiate play dates or social get-together's? *
Your answer
What teaching strategies work well for your child? *
Your answer
Please let us know 2 or 3 hopes you have for your child's experience at camp, keeping in mind that camp is a brief period of time *
Your answer
Please describe any additional considerations that we should be aware of. *
Your answer
I understand that I will have to pay a $20.00 registration fee at the start of each session. *
Required
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