Summer Camp Registration - Imprints Pediatric Therapy

1. Camper Information

Child Name

Date of Birth

Age

Parent/Guardian

Phone

Emergency Contact

Authorized Pick-Up Persons

Camp Session Preference

Morning Session (9:00 AM – 12:00 PM) Afternoon Session (1:00 PM – 4:00 PM) Either session works

Select Camp Week(s)

July 6–10 July 20–24 July 27–31 August 3–7 August 10–14 August 24–29

2. Health & Safety Profile

Allergies: None Yes

Please specify allergies

EpiPen required: No Yes

Medical diagnoses

Toileting: Independent Needs support In progress

Elopement risk: No Yes

Sensory triggers

Regulation strategies that help

Communication supports

3. Medication Authorization

Medication during camp hours? No Yes

Medication

Time

Dosage

Instructions

Parent consent for staff to administer medication. Initial:

All medications and allergies have been disclosed on intake forms.
Emergency medication (EpiPen/inhaler) has been provided if required.
I understand medication will only be administered with signed consent.

In the event of illness or injury:

I authorize Imprints Pediatric Therapy staff to provide basic first aid.
I authorize staff to contact emergency services if necessary.
I understand I will be contacted immediately in case of emergency.
I am responsible for any medical costs incurred.

Child's Health Card # (optional)

Signature (type your full name)

Date

4. Payment & Cancellation Policy

Camp Fee: $680/week Full week registration required. E-transfer $680 to info@imprintspediatrictherapy.com

Cancellation policy: 2 weeks' notice required. A $75 administration fee will be withheld.

Signature (type your full name)

Date

By submitting, you agree to the terms above and confirm all information is accurate.

Registration Submitted Successfully!

Thank you for registering. We will review your application and contact you shortly at the email provided.

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IMPRINTS PEDIATRIC THERAPYSUMMER CAMP REGISTRATION