Child's Name: *
Nickname
Birthday
Child's Diagnosis/Medical Conditions *
Does your child have: (Check all that apply)	Private Insurance Medicaid Transportation to Camp None of the avove
Can you volunteer at camp?	Yes No
If you can volunteer, please list dates and times
Case Worker/Dis.Board/Early Interventionist
How did you hear about us?
Which session do you want?	Session I Session II Both
Child's Address
Child's City
State
Zip
Primary Contact
Address
City
State
ZIP
E-mail: *
Telephone Number:
Additional Contact Number: