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Crossway Academy Academic Summer Camp Registration
Week(s) you are registering for:
*
June 28 - July 1
July 5-8
August 2-5
August 9-12
*
Indicates required field
Child's Name
*
First
Last
Date of Birth
*
Age
*
Diagnosis
*
School Name
*
Daytime Phone Number
*
Family Email
*
Type of Placement in school
*
Grade level
*
Describe your child's communication level
*
Does your child have any significant behavior issues? If so, please explain
*
Does your child display age appropriate toileting and feeding skills? If not, please explain
*
Parent/Guardian Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Mother/Guardian Cell Phone Number
*
Father/Guardian Cell Phone Number
*
Date of Last Medical Exam
*
Is your child in good health to participate in outdoor activities?
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Yes
No
For short periods of time only
Are there any specific physical or emotional restrictions? If so, please explain
*
Allergies
*
Medications
*
Does you child need an Epi Pen or Inhaler? If yes, please send these on the first day
*
Epi Pen
Inhaler
None of the Above
*For Medical Needs, your insurance company is responsible for transportation*
Photos of my child may be used on the Crossway Academy website
*
Yes
No
Please list any friends you would like to receive camp information. Names and email addresses:
*
Parent/Guardian Signature. I certify that all information submitted on this form is true and that I have the authority to register the above child for summer camp.
*
Date
*
Submit
Home
About
About Crossway
Prospective Students
Educational Tutoring
After School Club
News
Calendar
Contact
Pay Now
Middle School
Summer Camp
Camp Registration
Volunteer Application
Crossway Blog
Therapy
