Register For Summer Camp Here: 

First Name*:
Last Name*:
Email Address*:
Phone Number:
City, State, and Zip Code:
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 names and phone numbers of two people 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*::
Emergency Contact Name:
Relationship to Camper:
Emergency Contact Number:
Transportation Alert: (alerts us to people you DO Not want to pick up your camper) As a parent of legal guardian, I DO NOT authorize my camper to be released to / picked up by the following persons

Medical Information

Camper's Primary Doctor*:
Doctor's Phone Number*:
Medical Insurance Name and 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:
Will this camper need to take medication during camp hours?*:
If yes, please list all medications:

Camper Profile

Camper Diagnosis/Diagnoses*:
Describe your camper: What are their likes/dislikes?*:
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 liks in a group setting?*:
Do they need support in the restroom?*:
Do they have a history of elopement/bolting away?*:
Does this camper have any challeneges with community safety skills that we should be aware of?*:
If yes, are there any tips/tools that work best when working with these challenges?:


Week 1 June 19th - June 23rd (NO CAMP MONDAY JUNE 19TH) - Please reach out to Alex at for availability.
Week 2 June 26th - June 30th *Please list AM, PM, or Full Day for each day or Full Week*::
Week 3: July 3rd - July 7th (NO CAMP TUESDAY JULY 4TH) *Please list AM, PM, Full Day, Full Week*:
Week 4: July 10th - July 14th *Please list AM, PM, or Full Day for each day or Full Week*:
Week 5: July 17th - July 21st *Please list AM, PM, or Full Day for each day or Full Week*:
Week 6: July 24th - July 28th *Please list AM, PM, or Full Day for each day or Full Week*:
Week 7: July 31st - August 4th *Please list AM, PM, or Full Day for each day or Full Week*:
Week 8 August 7th - August 11th *Please list AM, PM, or Full Day for each day or Full Week*::
Week 9: August 14th - August 18th - please reach out to Alex at for availability
Week 10: August 21st - August 25th *Please list AM, PM, or Full Day for each day or Full Week*:
Week 11: August 28th - September 1st *Please list AM, PM, or Full Day for each day or Full Week*:


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 confirm that 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, you will be taken to a payment page to make your deposit. we are asking that families make a $250 non-refundable deposit (this is equal to one full week of camp and will be applied to your camp invoice) to hold their camper’s spot. However, if you wish to attend for a total of less than five days throughout the entire summer, you can make a deposit of your exact daily amount. You may also pay for all your days upfront.