Summer Camp 2022 Application Form

Child's Name(Required)

First Middle Last Nickname

Date of Birth(Required)

Gender(Required)

Male

Female

Non-binary

Age(Required)

Grade entering Fall 2022:(Required)

Has this child ever attended a Help Group camp before?(Required)

Yes

No

If YES, please specify which camp and date(s) of camp?(Required)

Parent/Guardian's Name(Required)

First Last

Email(Required)

Mobile Phone(Required)

Home Phone

Would you like to add an additional parent/guardian?(Required)

Yes

No

Second Parent/Guardian's Name

First Last

Second Parent/Guardian's Email

Second Parent/Guardian's Mobile Phone

Second Parent/Guardian's Home Phone

Does your child have an IEP?(Required)

Yes

No

If YES, what is their educational label/diagnosis?(Required)

Does your child have any specific diagnoses?(Required)

Yes

No

If YES, Please list each diagnosis and when your child was diagnosed?(Required)

Are you a Regional Center client?(Required)

Yes

No

Will you require a payment plan?(Required)

Yes

No