Registration Form for Art & Music Camp for Special Needs Children (Day Camp for 5 to 13 year olds with traumatic brain injury, cerebral palsy, and physical or cognitive disabilities) June 11-15, 2018
At this time we are accepting applications for our 2018 camp. All of the information requested is very important to us - not only to determine if this camp is the right camp for your camper, but also to help us in caring for your child while they are at camp if they are accepted. We need all the details on your child to ensure their safety. Your camper's instructor will use the information you provide as an aid at camp - please take the time to give us complete answers! If you are unsure how to answer or have any questions please e-mail the program director at progmgr@aikencenterforthearts.org
How did you hear about this camp? *
Your answer
CAMPER'S last name *
Your answer
CAMPER'S first name *
Your answer
Name CAMPER wishes to be called *
Your answer
Date of birth *
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/
DD
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YYYY
Age (at camp) *
Your answer
PARENT or GUARDIAN full name *
Your answer
Street address *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
County *
Your answer
GUARDIAN'S home phone *
(please give us alternative phone numbers, as we need more than one way to contact you while your child is at camp.)
Your answer
GUARDIAN'S cell phone *
(please give us alternative phone numbers, as we need more than one way to contact you while your child is at camp.)
Your answer
GUARDIAN'S work phone *
(please give us alternative phone numbers, as we need more than one way to contact you while your child is at camp.)
Your answer
GUARDIAN'S email address *
Your answer
Emergency contact's NAME *
Your answer
Emergency contact's RELATIONSHIP TO CAMPER *
Your answer
Emergency contact's PHONE NUMBER 1 *
Your answer
Emergency contact's PHONE NUMBER 2 *
Your answer
Name(s) of individuals allowed to pick-up camper *
Your answer
Camper's Primary Care Physician and phone number *
Your answer
Will you or an aide be accompanying your child for the week? *
Do we have permission to photograph your child for promotional purposes? *
Which times can your camper attend? *
Required
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