Summer Registration Form

Registration Form

Please fill in the form below.
Parent/ Guardian

PrefixFirst NameLast Name
Parent/ Guardian

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Student Name

First NameLast Name
D.O.B
Diagnosis
Current School
Please list any behavioral concerns:
Behaviors, reinforcers,
Does your student have seizures
Primary Doctor
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Emergency Contact Name
Emergency Contact Number

Area CodePhone Number

Select weeks of participation

Rows	Full Week
Week 1 June 5 - June 9
Week 2 June 12 - June 16
Week 3 June 19 - June 23
Week 4 June 26- June 30
Week 5 July 10 - July 14
Week 6 July 17 - July 21
Week 7 July 24 - July 28

Camp Hours Monday - Friday 9:00am - 3:00pm

Weekly Tuition: $375

Ages 4-14

My Products

Registration Fee$100.00

Summer Camp Tuition$375.00

Weeks selected
Item subtotal:

Enter coupon

Total $0.00

We have a very limited number of spaces availabe! A one time registration fee of 100$ and a completed online registraton form will be required to hold a space for your student. Registration is not considered completed if full payment is not made.

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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