(Please note that completing this form does not register your child for camp.)

General Information
Child's Name *
Child's Name
Address *
Address
Date of Birth *
Date of Birth
Gender *
Please list all.
Please list all.
Primary Physician's Phone *
Primary Physician's Phone
Has your child attended Camp Ability in the past? *
Mother's Name
Mother's Name
Mother's Phone
Mother's Phone
Mother's Address
Mother's Address
Father's Name
Father's Name
Father's Phone
Father's Phone
Father's Address
Father's Address
Please check ALL weeks you wish your child to attend. *
Please check ALL hours you wish your child to attend. *
I consent to and authorize the use and reproduction by Special Kids of any and all photographs/audio/visual materials taken of my child for promotional material, educational activities, and/or for any other use for the benefit of the program. *
Medical & Behavioral Information
Does your child have seizures? *
If yes, what was the date of your child's last seizure?
If yes, what was the date of your child's last seizure?
Does your child have a feeding tube? *
Does your child need assistance with feeding? *
Does your child use any type of assistive device? *
Does your child require assistance in transfers? *
Is your child toilet trained? *
Does your child need assistance with toileting? *
Is your child verbal? *
Is your child able to follow 2 to 3 step directions? *
Does your child know how to swim? *
Has your child ever displayed aggressive behaviors towards his or herself? *
Has your child ever displayed aggressive behaviors towards others? *
About Your Child
The more information we have, the better we will be able to care for your child.
Emergency Contact
I give permission for my child to be transported by the Emergency Contacts included below if I am unable to be reached. *
Today's Date *
Today's Date
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #1 Phone *
Emergency Contact #1 Phone
Emergency Contact #2 *
Emergency Contact #2
Emergency Contact #2 Phone *
Emergency Contact #2 Phone
Emergency Contact #3
Emergency Contact #3
Emergency Contact #3 Phone
Emergency Contact #3 Phone