Arts For All Abilities Camp Registration Form

Camper's Name

First Name

Last Name

Preferred Name

Camper's Date of Birth

YYYY

Gender

What is your camper's primary diagnosis?

Camper TShirt Size

Parent/Guardian's Name

First Name

Last Name

Relationship to Camper

Parent/Guardian's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Home Phone

(###)

###

####

Parent/Guardian's Cell Phone

(###)

###

####

Parent/Guardian's Email

Is your camper non verbal?

Does your camper use ASL to communicate?

Does your camper use a communication board?

Does your camper use gestures to communicate?

Does your camper need assistance with toileting?

Does your camper have a special diet? (i.e. gluten free, etc.)

Is your camper allergic to any foods?

If Yes Please Explain

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Use this space to list ANY special instructions to help us better care for your camper:

Additional Comments:

I give permission to Presser PAC to use any photographs or media of student in promotional materials, commercials, and on web site

Yes

Release

I, the undersigned parent/guardian of this student, a minor, do hereby release and discharge PPAC from any and all claims for personal injuries. By entering your name in the section below you agree to these terms.

Parent/Guardian Release Agreement

First Name

Last Name