Parent/Caregiver Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
MM
DD
YYYY
Child's Current Grade Level
Rising K
K
1st
2nd
3rd
4th
5th
What is your child's primary language? (If multilingual, please list all languages your child speaks at home).
*
Tell us about your child’s strengths.
*
What areas or challenges does your child need additional support in to thrive throughout their day?
*
Does your child have a formal diagnosis from a medical professional?
*
Yes
No
If yes, please describe:
Does your child have any allergies or dietary restrictions?
*
Yes
No
If yes, please specify:
Has your child successfully participated in a full-day drop-off program before?
*
Yes
No
Would your child be able to attend all 5 days of this camp?
*
Yes
No
Would your child have reliable transportation to be dropped off at 9:00am and picked up promptly by 4:00pm all 5 days of camp?
*
Yes
No
Please select your #1 preferred week:
*
Please select your #2 preferred week:
*
Is there anything else you would like us to know about your child to help us provide the best experience for them?
*
How did you hear about this program?
Thank you! Your application has been submitted.
As part of our process, we will be emailing a select number of families a comprehensive Needs Assessment Form for additional information. Completing this form will be required to help us ensure we can provide the best experience for your child.
We appreciate your interest and will be in touch soon if your application has been chosen!
