STAR Institute Summer Camp Intake Form

Today's Date:

MonthDayYear

Completed by:*

Child's Name:*

First NameLast Name

Age:

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth:

MonthDayYear

Sex:

MF

I am interested in (Summer 2021):*

Superhero in Training Summer Camp (ages 6-9) • Monday-Friday (July 19-July 30) • 3:15-4:30PM

How did you hear about our Summer Camps?*

Parent's Name:*

First NameLast Name

Home Phone:*

Area CodePhone Number

Cell Phone:

Area CodePhone Number

E-mail*

Emergency Contact Name:

Emergency Contact Phone Number

Area CodePhone Number

List any previous diagnoses:

List any previous treatment at STAR Institute or other places: (include any current or previous therapies and testing)

Please describe your concerns for your child in regards to social interaction:

Your child's interests:

Describe play on the playground with other children:

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 sensory sensitivities (ex: auditory, tactile, etc.?)

Does your child have physical challenges?

Does your child have any allergies or other important medical conditions?*

Your child's preferred t-shirt size*

Will you be receiving Developmental Pathways funding for this group?*

YesNo

Will you be receiving funding from Rocky Mountain Human Services?*

YesNo

Enter the message as it's shown*

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.

STAR Institute Summer Camp Form