1st Quarter Respite Registration 2021 1st Quarter Respite Registration Question Title * 1. Camper First and Last NamePlease double check spelling before submitting. Question Title * 2. Have you sent in your...*we must have all of these items before you can fill out this form* 2021 Application Immunization Records and Health History Form Physical (valid for 2 years) 3 Signed Waiver Forms (located in the application) CCSP or ICP from your case manager Funding (Notice of Decision or private payment) Case manager's email address Question Title * 3. Please choose the 1st Quarter respite sessions you would like to request R1 January 8-10 (Under the Sea) R2 January 22-24 (Mission Impossible) R3 February 5-7 (Futuristic Fun) R4 February 19-21 (Jungle Safari) R5 March 5-7 (Circus Extravaganza) R6 March 19-21 (Camp Sunnyside Olympics) By submitting this form, you understand that this is a request for the dates listed and NOT a confirmation that you have been registered. You will receive a letter in the mail that will show whether you have been confirmed or added to the waitlist. Question Title * 4. Person filling out survey? Case Manager Guardian Other (please specify) Submit