Screen Shot 2017-03-20 at 2.02.23 PM.png
General Information
Camper Name *
Camper Name
Date of Birth *
Date of Birth
Gender *
For the upcoming school year.
Parent/Guardian 1 *
Parent/Guardian 1
Parent/Guardian 1 *
Parent/Guardian 1
Parent/Guardian 2
Parent/Guardian 2
Parent/Guardian 2
Parent/Guardian 2
Address *
Emergency Contact
Name *
Phone *
Please include name, relation, and phone number.
Emergency Medical Information
Doctor's Name *
Doctor's Name
Phone *
Health History
We need the following information in detail to help us serve your child effectively. Any changes to this information should be provided to the Camp Director upon participant’s arrival the first day of camp.
Personal Needs
*Special utensils, straws, and any assistive devices need to be provided by the camper*
(i.e. seizures, self-injurious behaviors, physical aggression, sensory sensitivities, etc.)
Please list (and attach, if needed) all known allergies and the management of the reaction.
Therapeutic Goals
The mission of Camp creARTive is to make art and music accessible to children with special needs. We want to tailor this experience to the needs of your child. Please share two things that you would like us to work on this week. They can include social, fine or gross motor, behavior, and/or speech goals.
Electronic Signature *
Electronic Signature
Today's Date *
Today's Date