FUSE Camp Application

Imagine Adventure Club

For ages 7-12 years old
Child's Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Age: *
Gender: *

M F

Parent's Name: *

First Name Last Name
Intake Completed By:
Best Phone Number: *

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Emergency Contact: *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
How did you hear about our Group? *
List any previous diagnoses:
Does your child have physical challenges? If yes, describe:
Does your child have any attention or behavioral concerns in groups or with peers? If yes, please describe:
Describe your child's current language skills: (length of sentences, how many step directions can he/she follow, does he/she answer questions, how easily can he/she be understood by peers)
Does your child have any allergies or other important medical conditions? *
Briefly describe any sensory sensitivities your child has (i.e. noise, texture, food, lighting etc.):
What is your child's level of experience using kitchen utensils and appliances (i.e. mixer, chopping, microwave, toaster, etc.)? *only required if applying for cooking group*
Describe your main concerns regarding your child's social skills:
I am interested in registering my child for the following group program timeframe: *

Spring Break (March 2022) Afterschool Sessions (March-May 2022) Summer (June-August 2022)
Please provide preferred days and times for selected sessions above:
Will you be receiving funding from Developmental Pathways? *

Yes No
Will you be receiving funding from Rocky Mountain Human Services? *

Yes No
By clicking submit, I acknowledge a deposit of $150 is required to secure a spot in a group. 30 days-notice prior to the start date of a group is required to cancel. If less than 30 days-notice is given, I recognize that the deposit will be forfeited.
Should be Empty:

Imagine Adventure Club