Camp Registration

Crossway Academy

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Crossway Academy Academic Summer Camp Registration

Week(s) you are registering for: *

August 3-6 (Crossway Carnival) August 10-13 (Crossway Carnival)

* 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? *

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

Services

Tutoring
After School Club
Occupational Therapy
Physical Therapy
Speech Therapy

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Crossway Academy
9111 Monroe Rd. STE 100
Charlotte, NC 28270

(P) 704.847.3911
(F) 704.847.2033

Home
About
Middle School
Summer Camp
- Camp Registration
Crossway Blog
Therapy