Register For Winter Break Camp Here! 

First Name:
Last Name:
Email Address:
Phone Number:
Address:
City, State, and Zip Code:
Age:
Birthday:
Gender:
Preferred Pronouns:
Parent/Guardian Name:
Parent/Guardian Address (if different from above):
Parent/Guardian Phone:
Parent/Guardian Email:
Parent/Guardian Name:
Parent/Guardian Address (if dfferent from above):
Parent/Guardian Phone:
Parent/Guardian Email:
Please provide the name and phone number of someone who we may contact in the event of an emergency and the parent/guardian(s) listed cannot be reached
Emergency Contact Name:
Relationship to Camper:
Emergency Contact Phone Number:
Transportation Alert: This alerts us to people you DO Not want to pick up your camper. As a parent or legal guardian, I DO NOT authorize my camper to be releasedto/ picked up by the following persons:
Names:

Camper Profile

Camper's Primary Doctor:
Doctor's Phone Number:
Does this camper have seizures:
If yes, please list the type and duration of seizures and the seizure protocol you follow:
Does this camper have allergies:
If yes, please list all allergies:
Describe your camper what are their likes and dislikes?:
Will this camper need to take medication during camp hours?:
If yes, please list all medications:
Camper diagnosis/diagnoses:
What is your camper like behaviorally? Please include all strategies that work well when engaging your camper if they are having some difficulties?:
What is your camper like in a group setting?:
Do they need support in the restroom?:
Do they have a history of elopement/running away?:
Does your camper have any challenges with community safety skills that we should be aware of?:
Are there any tips/tools that work best when working with these challenges?:

Winter Break 2025 Camp Dates

Camp days are split into morning session (9:00 a.m.–1:00 p.m.) and afternoon session (1:00–5:00 p.m.). Campers may sign up for the full day or a single session. Please review the camp days below and list which sessions you'd like to sign up for in the space below. (Make sure to indicate morning session, afternoon session, or full day!)
Monday, December 22
Tuesday, December 23
Wednesday, December 24 (morning session only)
Monday, December 29
Tuesday, December 30
Wednesday, December 31
Friday, January 2
Please list all days you'd like to sign up for here (note if morning, afternoon, or full day needed):

Releases

I hereby release PSL Services/STRIVE, and its employees/volunteers of any responsibility or liability for any injury and/or illness derived from participation in the Camp STRIVE program:
I hereby give permission for my camper to participate in any off site field trips which are part of the Camp STRIVE program:
I give consent for transportation to a medical facility (by ambulance or employee vehicle) in the event of an emergency:
I understand that the permission I have given by signing this form is a material inducement to acceptance of my camper as a Camp STRIVE participant. I also confirmthat I have given PSL Services/STRIVE complete and accurate information on my child:
I understand that I am responsible for payment of any and all days registered unless given notice of schedule change to staff by the end of the day prior to scheduled session:
Pictures of camper and camper's activities may be taken and used for publicity purposes including but not limited to publications in commercial periodicals and program newsletters:
Release and Consent Form Parent/Guardian Signature:
Release and Consent Form Date:
Once you hit the submit button, a STRIVE staff will reach out within one business day to confirm your registration. You will also be sent an invoice for a deposit to hold your spot. If you are attending for a full week or more, the deposit is $300 (one full week of Camp STRIVE). If you are attending for less than a full week, your deposit will equal your total payment.