1st Quarter Respite Registration 2019

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* 1. Camper First and Last Name
Please double check spelling before submitting.

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* 2. Have you sent in your...
we must have all of these items before you can fill out this form

2019 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

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* 3. Please choose the 1st Quarter respite sessions you would like
to request

R1 Under the Sea (Jan 4th - 6th)

R2 Mission Impossible (Jan 18th-20th)

R3 Pursuing Picasso (Feb 1st - 3rd)

R4 Jungle Safari (Feb 15th - 17th)

R5 Circus! (Mar 8th - 10th)

R6 Camp Sunnyside Olympics (Mar 29th - 31st)

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* 4. Do you want to sign up for Spring Break Camp? (March 18 - 21 from 8am - 5pm) Requires additional funding.

Yes

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.

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* 5. Person filling out survey?

Case Manager

Guardian

Other (please specify)

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*

Question Title

* 3. Please choose the 1st Quarter respite sessions you would like to request

Question Title

* 4. Do you want to sign up for Spring Break Camp? (March 18 - 21 from 8am - 5pm) Requires additional funding.

Question Title

* 5. Person filling out survey?

* 1. Camper First and Last Name
Please double check spelling before submitting.

* 2. Have you sent in your...
we must have all of these items before you can fill out this form

* 3. Please choose the 1st Quarter respite sessions you would like
to request