DAY CAMP REGISTRATION

Child's Name

First Name

Last Name

Age of Child

Parent's Name

First Name

Last Name

Which Day Camp are you registering for?

Email Address

Best Phone Contact During Day

(###)

###

####

Does your child have any allergies?

List any allergies:

Special Needs or Concerns

Toileting

Eating

Communication

Mild Behavior (noncompliance, tantrums, etc.)

Aggressive Behavior

Social Skills

Elopement

Other

Other Concerns

Please describe any other special needs or other concerns not listed above:

List several toys, activities, topics your child ENJOYS

List several things that you child does NOT enjoy or that bother your child

Special Instructions: