Speak, Learn, and Play | Camp Application

Is your child:*

Child's Name*

Date of Birth*

Parents' Names*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Allergies/Special Alerts

Child's Diagnosis (if known)

School Name*

Grade*

What services (if any) does your child currently receive in school?

How does your child engage in small groups?*

Is your child able to feed him/herself?*

Is your child toilet trained?*

If yes, how does your child let you know s/he needs to use the bathroom?*

What does your child like to play with?*

How does your child manage frustration/anger?*

Which camp session(s) are you interested in?*

Thank you for your interest! We will get back to you as soon as possible to set up a screening.