Camper Name *

Please submit additional campers separately

First Name

Last Name

Camper Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Preferred Weeks *

Please select preferred weeks for enrollment (minimum two week required)

Week of 06/30 (No camp 07/04)

Week of 07/07

Week of 07/14

Week of 07/28

Week of 08/04

Week of 08/11

Week of 08/18

Does the camper have a history of seizures? *

Yes

No

Yes, but has not experienced seizures in more than 12 months

Does the camper require assistance in the bathroom? *

Is fully independent with toileting

Can complete toileting independently but may need supervision

Can complete most steps independently

Cannot use toilet independently