Child's Name* First Last Date of Birth* MM slash DD slash YYYY Parent's Name/s*Email Guardian #1* Email Guardian #2 Address* Street Address City State ZIP / Postal Code Home PhoneCell PhoneWork PhoneAllergies or other precautions:Name of person dropping off/picking up your child if different from guardian:PhoneEmail What would you most like your child to get from camp?Please describe your child’s social and play skills:Please describe your child’s sensory motor, gross and fine motor skills, please note any safety concerns:Please describe your child’s speech and language skills:Is your child independent in going to the bathroom, dressing and feeding, if not, please describe the level of assistance they are likely to need during camp:Does your child have an aid at their current school placement? Yes NoIf you answered “YES”, please discuss the possibility of the aid attending camp during the initial camp consultation.Consent & AgreementI would like to enroll my child in Camp Splish Splosh. I give permission for FUNdamentals and Building Blocks Therapy and its associates and Fairfax FUNdamentals to provide treatment and services at the camp. I understand that photographs/videos will be taken at the camp and used for the sole purpose of sharing information about the summer camp with other parents and professionals and for our end of camp slide show. I understand that half of the cost of the camp is due with registration and the other half is due by June 1, 2019.Check Below to indicate Agreement* I would like to enroll my child in Splish SPLOSH. I give permission for FUNdamentals and Building Blocks Therapy and FUNdamentals to provide treatment and services during the summer program. I understand that photographs/videos will be taken during the day and used for the sole purpose of sharing information about the summer program with other parents and professionals and for our end of program slide show. I understand that $100 is due with registration and the remaining amount is due by June 1, 2021. I understand that health insurance policies and reimbursement are between myself and my insurance company. I understand that services provided by FUNdamentals (Occupational Therapy) and FUNdamentals and Building Blocks Therapy (Speech Therapy) for the above individual are charged directly to me and I am responsible for payment in full. This is an interdisciplinary camp, please check with your provider regarding reimbursement for services. Some carriers may reimburse for both therapies, one but not the other, or not at all. You will be given an itemized bill with appropriate codes at the end of Splish SPLOSH by FUNdamentals and FUNdamentals and Building Blocks Therapy for the hours your child attended the program. I understand that due to the many restricted dietary needs of the children, FUNdamentals and Building Blocks Therapy and FUNdamentals are not able to provide a snack or lunch and that I will pack a snack and lunch daily. Due to the many allergies of the children, Splish SPLOSH must be a peanut free environment. By checking this box, I agree that I have read, understand and will abide by the Consent & Agreement written above:PhoneThis field is for validation purposes and should be left unchanged.Option: Download a PDF if you prefer to fill out the form by hand and deliver or mail to us.
