Teen Summer Camp Registration

ALL SESSIONS ARE CURRENTLY FULL. If you would be interested in joining the waitlist for either/both months, please sign up below. You will not be charged upon registering for the waitlist. Families will be alerted to openings in the order that they have registered on the waitlist.

Person with Down Syndrome

First Name

Last Name

Address

City

State

Zip Code

County of residence

Date of Birth

Cell

Parent/Caregiver

First Name

Last Name

Cell Phone

Home Phone

Social Determinants for Pricing (select all that your loved one or your family currently receive):

MedicaidSNAP/EBT/Food assistanceFree and Reduced LunchSSI or SSDI (Social Security Benefits)DCF Childcare SubsidyNone of the above

Dates of Attendance

Please select which sessions you would like your teen to attend (may select one or both):

WAITLIST - June Sessions (June 10th, June 17th, June 24th)WAITLIST - July Sessions (July 8th, July 15th, July 22nd)

Please select which sessions you would like your teen to attend (may select one or both):

ALL SESSIONS ARE CURRENTLY FULL. If you would be interested in joining the waitlist for either/both months, please sign up below. You will not be charged upon registering for the waitlist. Families will be alerted to openings in the order that they have registered on the waitlist.

WAITLIST - June Sessions (June 10th, June 17th, June 24th)WAITLIST - July Sessions (July 8th, July 15th, July 22nd)

How does your teen communicate?

Any potential challenging behaviors to be aware of prior to group?

Any allergies, sensitivities, or other medical concerns to be aware of prior to group?

Other special considerations or comments?

Payment Information

Name on Card

Card Number

CVV

I agree to support this mission further by covering my 3% credit card processing fee

Credit Card Fee Amount

Total Amount

SalesforceCampaignID

20XX - Campaign Salesforce ID. This ID is changed every year with the new years campaign ID.

LeadSource

Contact Information