2021 Summer Camp Participant Sign-Up
Please complete as accurately as possible.
Today's Date:
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Month
-
Day
Year
Date
Patient's Name:
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First Name
Last Name
Patient's Date of Birth
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Month
-
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 7th - July 1st
Session 2: July 12th - August 6th
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
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9:00 am - Noon
1:00 pm - 4:00 pm
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
Print Form
Submit
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