Register For Winter Break 2024 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:
Emergency Contact Name*:
Relationship to Camper*:
Emergency Contact Phone Number*:
Please share any information you think we should know about your camper (likes/dislikes, behaviors in a group setting, community safety skills, etc.)*:
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::
Does this camper need support in the restroom?:
Does this camper have a history of elopement/bolting away?*:

February Camp Dates 2025

STRIVE is closed Monday 2/17 and there is Camp STIRVE
Tuesday, 2/18:
Wednesday, 2/19:
Thursday 2/20:
Friday, 2/21:

February Camp STRIVE 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*: