Parents Name *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Campers Name *

First Name

Last Name

Siblings Name*

*Only complete if you plan to have a neurotypical sibling attend summer camp this year

First Name

Last Name

Respite *

We offer before and after program respite, please signify your respite needs below. Space not guaranteed.

Some or all mornings between 8-10am

Some or all afternoons between 3-5pm

Both mornings and afternoons

I will not need morning or afternoon respite this summer