2021 Summer Camp Intake

2021 Summer Camp Participant Sign-Up

Please complete as accurately as possible.
Today's Date: *

Month Day Year
Date
Patient's Name: *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Date
Patient's Gender: *

Male Female
Diagnosis (if applicable):
List current medications (if applicable):
Patient's current physician: *
Physician's office/clinic name: *
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 *
Session Preference *

Session 1: June 7th - July 1st Session 2: July 12th - August 6th Both sessions
Location Preference *

Marsing (school) Parma (school) Meridian (We are Better Together clinic)
Time Preference *

9:00 am - Noon 1:00 pm - 4:00 pm
Area(s) of Interest *

Speech-Language Therapy Occupational Therapy (includes self-regulation, sensory processing, self-care, coordination, handwriting, etc.) Both
Contact Information
Parent/guardian's name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone number *

Area Code Phone Number
E-mail *
Emergency contact: *

First Name Last Name
Contact's relationship to patient: *
Contact's phone: *

Area Code Phone Number
I give my permission to send text messages to my personal cell phone: *

Yes No
Insurance/Medicaid Information
Child's Primary Coverage *

Insurance Medicaid Private Pay (cash/check)
Referral Information
How did you hear about us?
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2021 Summer Camp Participant Sign-Up

Registration and School Information

Contact Information

Insurance/Medicaid Information

Referral Information