Register For Summer 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: (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
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 / 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/bolting 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?*:

Summer 2025 Camp Dates

Week 1: June 16th - June 20th (please list specific half days, full days, or full week. STRIVE IS CLOSED THURSDAY JUNE SO THERE WILL BE NO CAMP):
Week 2: June 23rd - June 27th (please list specific half days, full days, or full week):
Week 3: June 30th - July 4th ((please list specific half days, full days, or full week. STRIVE WILL BE CLOSED FRIDAY, JULY 4TH SO THERE WILL BE NO CAMP THAT DAY):
Week 4: July 7th - 11th (please list specific half days, full days, or full week):
Week 5: July 14th - 18th (please list specific half days, full days, or full week):
Week 6: July 21st - July 25th (please list specific half days, full days, or full week):
Week 7: July 28th - August 1st (please list specific half days, full days, or full week):
Week 8: August 4th - August 8th (please list specific half days, full days, or full week):
Week 9: August 11th - August 15th (please list specific half days, full days, or full week):
Week 10: August 18th - August 22nd (please list specific half days, full days, or full week):
Week 11: August 25th - August 29th (please list specific half days, full days, or full week):

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 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, 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.