Social Camp Enrollment Form
  • Social Camp Enrollment Form

  • Are you registering for the first time? (If your child has attended prior weeks of Social Camp, select "no"
  • Format: (000) 000-0000.
  • Acknowledgement of Risk

  • In consideration of the services of Firefly Therapy Clinic their officers, agents, employees, and stockholders, and all other persons or entities associated with those businesses (hereafter collectively referred to as “FTC”) I agree as follows: Although FTC has taken reasonable steps to provide me and/or my child with appropriate equipment and skilled guides so I can enjoy an activity for which I may not be skilled, FTC has informed me this activity is not without risk. Certain risks are inherent in each activity and cannot be eliminated without destroying the unique character of the activity. These inherent risks are some of the same elements that contribute to the unique character of this activity and can be the cause of loss or damage to my equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death. FTC does not want to frighten me or reduce my enthusiasm for this activity, but believes it is important for me to know in advance what to expect and to be informed of the inherent risks. The following describes some, but not all, of those risks. The hazards of walking on uneven terrain, slips and falls; slipping and falling on the rock wall, crashing on trampoline, falling from the swing, being hit by a ball or toy, falling from a chair, choking, allergic reaction; my own physical condition and the physical exertion associated with these activities. I am aware that FTC entails risks of injury or death to any participant. I understand the description of these inherent risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death. I agree to assume and accept full responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary; no one is forcing me to participate, and I elect to participate in spite of and with full knowledge of the inherent risks. I acknowledge that engaging in this activity may require a degree of skill and knowledge different from other activities and that I have responsibilities as a participant. I acknowledge that the staff of FTC has been available to more fully explain to me the nature and physical demands of this activity and the inherent risks, hazards, and dangers associated with this activity. I certify that I am fully capable of participating in this activity. Therefore, I assume and accept full responsibility for myself, including all minor children in my care, custody, and control, for bodily injury, death, or loss of personal property and expenses as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence in participating in this activity. I have carefully read, clearly understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon me, my heirs, assigns, personal representative, and estate and for all members of my family, including minor children.

  • Parent/ Guardian Drop off - Pick Up Policy

  • Firefly Therapy Clinic allows drop off and pick up of children for social camp. We require all parents, guardians and others who are dropping off, or picking up to follow these Guidelines.

    • Bring the child into the waiting room and stay with them until the staff has arrived to take them back for camp. Please do not leave children unattended in the waiting room
    • Arrive a minimum of 5 minutes prior to the end of camp to pick up the child
    • Children will NOT be released to anyone other than the parent or guardian signing this intake packet, unless listed below
    • Should you require a non listed individual to pick up your child, please contact the clinic prior to the appointment so we may update our list. 

    STAFF WILL NOT RELEASE A CHILD TO ANYONE other than the signer of this intake, without them being added to this list OR with verbal or written consent.

  • Register for up to 6 weeks or purchase 1 week at a time

    prevnext( X )
    Week 1. Week of June 8 - 12
    Week 1

    Week of June 8 - 12

    $250.00$250.00
      
    Week 2. Week of June 15-19
    Week 2

    Week of June 15-19

    $250.00$250.00
      
    Week 3. Week of June 22-26
    Week 3

    Week of June 22-26

    $250.00$250.00
      
    Week 4. Week of June 29-July 4
    Week 4

    Week of June 29-July 4

    $250.00$250.00
      
    Week 5. Week of July 6 - 10
    Week 5

    Week of July 6 - 10

    $250.00$250.00
      
    Week 6. Week of July 13-17
    Week 6

    Week of July 13-17

    $250.00$250.00
      
    Total
    $0.00$0.00

    Payment Methods

    creditcard
    After submitting the form, you will be redirected to Apple Pay to complete the payment.
  • Payments are made on a weekly basis and cover 5 days of Camp. No refunds are given for partial attendence. Payments must be made prior to the start of each camp week

  • Should be Empty: