Leaps & Bounds Registration – Intensive Therapeutics

Child’s Name *

First

Last *

Last

Date of Birth *

Age *

Gender

Parent’s Name *

First

Last *

Last

Preferred Phone *

Preferred Phone Type *

Alternate Phone #1 *

Alternate Phone #1 Type *

Alternate Phone #2

Alternate Phone #2 Type

Email *

Address *

Address Line 2

City *

State *

Postal Code *

Country

Camp Session *

Please provide specific weeks/dates

Camp Options *

Add-On Option

Would you like your child to participate in “Pizza Fridays”? *

Yes

Is your child on medications? *

Yes

Types of medications

Does your child have allergies? *

Yes

Please list allergies

Does your child exhibit any behaviors? If yes, please explain.

YesYes

Any other pertinent information?

What are one or two realistic / functional goals you would like to see your son / daughter achieve during this program?

Please confirm below: