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Summer Camp Registration Form
August 4 - 15
9:30 - 3:00
Location: Congregation Beth Am
Cost: $550 per week $1000 session

Your Name
Childs Name
Address
City, State, Zip
Phone / Cell Phone
Email

*Additional Information(for first time campers)

What are you child’s favorite activities?

 
Is your child completely toilet trained?  
Preference for Boy/Girl Volunteer?  

What makes your child happy? (special toys, special activities)

 

What makes your child upset?

How does your child communicate his/ her needs or thoughts?

Tell us about your child’s behavior. Is he/she ever aggressive?

 

What is the best method of handling the situation?

 

Please e-mail/mail a diagnostic assessment, an IEP, or other related documents (if applicable)
to 3900 Fabian Way, Palo Alto, CA 94303 or to ezzy@bayareafc.org

  
Do you permit your child’s photo to be used for publicity purposes.  

       Medical Emergencies
In case of an emergency, when neither parent can be reached, please list the name
and information of the person who can take responsibility of your child.

Name:

Relationship to child:

Cell Phone:

Home Phone:

By typeing your name below, you release the Friendship Circle, its providers and administrators, from ALL liability for any incident, which affects the health, welfare, or safety of my child in the provision of such service.

Name
Date

Click to Submit Registraiton - Payment options on the Next Page

 

 

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