☀️🏕️

ENROLLMENT FORM

Summer Camp 2026

Presented by GLAD Therapy Talks

Please complete all sections. Information is kept strictly confidential.

👦 Student Information

Full Name of Child *

Date of Birth *

Age

Gender *

Primary Language Spoken at Home

Nationality

👨‍👩‍👧 Parent / Guardian Information

Primary Contact

Parent / Guardian Name *

Relationship to Child

Phone *

Email Address *

Secondary Contact (optional)

Parent / Guardian Name

Relationship to Child

Phone

Email Address

📅 Program Selection & Attendance

Camp Term *

Month 1 (June 29th – July 24th)Month 2 (July 27th – August 21st)Full 2-Month ProgramCustomize

Daily Track *

Half-Day 8:30 AM – 12:00 PMFull-Day 8:30 AM – 3:30 PM

🚗 Authorized Pick-Up Persons

Other than parents. Staff will verify ID upon pickup.

Name

Phone

Relationship

Name

Phone

Relationship

🏥 Medical & Sensory Health Declaration

Known Allergies

No known allergiesYes, please specify

Food, peanuts, milk, insects, medicine, latex

Medical Conditions

No conditionsYes, please specify

Asthma, epilepsy, heart conditions, etc.

Current Regular Medications

Sensory / Behavioral Notes

NoYes, please specify

Does your child dislike loud noises, specific textures, or crowd overwhelm?

Toilet Training Status

Fully TrainedNeeds RemindersUses Diapers

For children ages 3–5

🌱 Therapeutic & Developmental Baselines

To help our specialist team support your child, please check any areas you'd love us to focus on:

👀 Eye Contact & Joint Attention🗣️ Speech, Vocabulary & Communication🪑 Sitting Stamina & Focus✏️ Fine Motor Skills (Writing, cutting, painting)🤝 Social Sharing & Turn-Taking💛 Emotional Coping & Frustration Tolerance

📋 Legal Agreements & Waivers

🚑 Emergency Medical Authorization

In a medical emergency, I authorize camp staff to seek professional emergency care if parents cannot be reached immediately. I accept responsibility for associated costs.

⚽ Liability & Injury Release

I understand activities include football, swimming, dance, and messy art. I release GLAD Therapy Talks, its directors, staff, and rental facility providers from liability for accidental injuries during standard camp activities.

🕐 Pick-Up & Late Fee Policy

Children must be collected on time. A late fee of $5 per 15 minutes applies starting 15 minutes post-dismissal.

📸 Media & Photo Release *

✅ I CONSENT to photos/videos of my child for internal parent updates and marketing.🚫 I DO NOT CONSENT to my child's image being used for public marketing.

✍️ Declaration & Signature

I have read, understood, and agree to all the terms, health declarations, and waivers above.

I confirm I have read and agree to all terms, waivers, and declarations in this form.

Parent / Guardian Name (Signature) *

Date

🔒 All information is kept strictly confidential by GLAD Therapy Talks