Summer Camp Registration Form

Summer Camp Registration Form

Please fill out this form to register your child for the summer camp and provide relevant information.
Eligibility Questions
Has the child been diagnosed with Autism Spectrum Disorder (ASD) and/or an Intellectual or Developmental Disability (IDD)?

Not Eligible
Thank you for your interest in the Management Care Services Sensory Center Summer Camp. At this time, our camp is specifically designed for children diagnosed with Autism Spectrum Disorder (ASD) and/or Intellectual and Developmental Disabilities (IDD). Based on your response, your child does not currently meet the eligibility requirements for this program. We appreciate your interest and encourage you to follow Management Care Services for future programs and community events.

Registration
Upload Psychological Evaluation here

Cancelof
Diagnosis checklist

Other
Services checklist

Receives Other Services
Child Information
Child Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Any known allergies
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
School Currently Attending
Grade Level
Parent/Guardian Information
Parent/Guardian Name

First NameMiddle NameLast Name
Relationship to Child
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contacts
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick-Up Persons
Behavioral & Sensory Information
Sensory sensitivities or triggers
Calming strategies that work best
Preferred communication methods
Is the child prone to elopement or wandering?
Behaviors staff should be aware of
My Products
prevnext( X )
Product Name
Non-Refundable Registration Fee

$100.00 Quantity

Total

$0.00
Payment Methods

Choose from one of the PayPal options to make your payment.
Should be Empty:

Not Eligible