Speak, Learn, and Play | Camp Application

Child's Name*

Child's Date of Birth*

Parents' Names*

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email*

Allergies/Special Alerts*

Where does your child go to school?*

What grade is your child in?*

What is your child's diagnosis (if known)?*

What services does your child currently receive?

If your child is currently receiving services outside of school, can Amy have permission to collaborate with those providers?

How does your child learn best?*

What are your goals for your child around self-regulation?*

What are your goals for your child around executive functioning?*

Thank you so much for your interest! We will get back to you as soon as possible.

From Chaos to Calm Application