Registration - Neuro Spark

Registration and Consent Form for Camp Activities

Please enable JavaScript in your browser to complete this form.

Child’s Full Name

Child’s Date of Birth

Date and time for Group Activities

Date

Time

Allergies (if any)

Dietary Restrictions

Contact number

is of Restrictions

Camp Goals

CONSENT TO SERVICE

The group activities will focus on the goals outlined for everyone by their parents.

The general areas of focus for this group are:

Group skills and group engagement
Peer social interaction
Social skills development
Outdoor walks and activities

Email ID

The group is supervised by a BCBA

Click or drag files to this area to upload. You can upload up to 5 files.

By signing here, I state that I am the legal parent, guardian or substitute decision-maker and hereby give my consent for to participate in camps and/or groups.

Name

Parent Signature

Click or drag a file to this area to upload.

Date

Witness Signature

Click or drag a file to this area to upload.

Date