Registration Form for Art & Music Camp for Special Needs (Day Camp for those with traumatic brain injury, cerebral palsy, and physical or cognitive disabilities) June 8-12 (ages 5-13) or June 15-19 (ages 14+)
At this time we are accepting applications for our 2020 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/adult while they are at camp if they are accepted. We need all the details on your child/adult 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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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 camper 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 camper 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 camper 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 camper for the week? *
Do we have permission to photograph your camper for promotional purposes? *
Which dates/times can your camper attend? *
Required
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