2022 Summer Camp Participant Sign-Up
Please complete as accurately as possible.
Today's Date:
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Month
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Day
Year
Date
Patient's Name:
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First Name
Last Name
Patient's Date of Birth
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Month
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Day
Year
Date
Patient's Gender:
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Male
Female
Other
Diagnosis (if applicable):
List current medications (if applicable):
Patient's current physician:
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Physician's office/clinic name:
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Registration and School Information
Session schedule subject to availability and change. A member of We are Better Together's staff will provide a confirmation of your child's enrollment.
Child's Current School
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Session Preference
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Session 1: June 6th - July 1st
Session 2: July 11th - August 5th
Both sessions
Location Preference
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Marsing (school) on Mondays and Wednesdays
Parma (school) on Tuesdays and Thursdays
Meridian (We are Better Together clinic) on Tuesdays and Wednesdays
Time Preference Specific times will be discussed with each family before sessions start. Session length will vary from 1-3 hours depending space availability and client needs.
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Morning
Afternoon
Either time works for me
Day Preference
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Both days
One day
Area(s) of Interest
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Speech-Language Therapy
Occupational Therapy (includes self-regulation, sensory processing, self-care, coordination, handwriting, etc.)
Both
Contact Information
Parent/guardian's name:
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
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Area Code
Phone Number
E-mail
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example@example.com
Emergency contact:
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First Name
Last Name
Contact's relationship to patient:
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Contact's phone:
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Area Code
Phone Number
I give my permission to send text messages to my personal cell phone:
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Yes
No
Mobile phone, if different from above:
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Area Code
Phone Number
Insurance/Medicaid Information
Child's Primary Coverage
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Insurance
Medicaid
Private Pay (cash/check)
Other
Referral Information
How did you hear about us?
Please Select
Doctor/Dentist Referral
Facebook/Instagram
School Staff
Friend/Family
Child T-Shirt Size
XS (5/6)
S (6/7)
M (7/8)
L (8/10)
XL (10/12)
Other
Print Form
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