Parent's Name

Email *

Phone *

Child's Name *

Child's Date of Birth *

Which June Camps (July 7-31) Would You Like To Attend? *

Speech Camp Tuesdays 9-10am

Kindergarten Prep Wednesdays 9-11am

Literacy Camp (5-7 year olds) Tuesdays 10-12pm

Literacy Camp (8-10 year olds) Thursdays 10-12pm

Food Explorers Wednesdays 11:30a-1:30pm

Tell Us A Bit About Your Child *

Does your child currently receive speech therapy? *

Y

N

Has your child been diagnosed with a speech sound disorder? *

Y

N

What goals do you have for your child's speech? *

What else would you like me to know about your child's speech? *

Does your child receive reading intervention at school or from a tutor? *

Y

N

Has your child been diagnosed with dyslexia or a reading disorder? *

Y

N

What grade did your child just complete? *

What goals do you have for your child's reading/writing? *

What else do you want me to know about your child? *

Has your child been diagnosed with a feeding disorder or ARFID? *

Y

N

List foods that your child loves. *

List foods that you would like your child to eat. *

Tell me more about your child's eating preferences or dislikes. *

List food allergies your child has

Total cost per camp is $400.

$200 deposit required to hold your child's spot.

Your card will be charged the remainder of the balance two weeks before camp date.

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