Register For February 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 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 / 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 2024 Camp Dates

Week 1: June 17th - June 21st *PLEASE EMAIL ALEX AT AWOODHOUSE@PSLSTRIVE.ORG FOR AVAILABILITY*
Week 2 June 24th - June 28th *PLEASE EMAIL ALEX AT AWOODHOUSE@PSLSTRIVE.ORG FOR AVAILABILITY*
Week 3 July 1st - July 5th (PM AVAILABILITY ONLY - NO CAMP THURSDAY JULY 4th) :
Week 4 July 8th - July 12th *PLEASE EMAIL ALEX AT AWOODHOUSE@PSLSTRIVE.ORG FOR AVAILABILITY*
Week 5 July 15th - July 19th *PM AVAILABILITY ONLY*:
Week 6: July 22nd - July 26th *please list AM, PM, or Full Day for each day or Full Week*::
Week 7: July 29th - August 2nd *PLEASE EMAIL ALEX AT AWOODHOUSE@PSLSTRIVE.ORG FOR AVAILABILITY*
Week 8: August 5th - August 9th *PLEASE EMAIL ALEX AT AWOODHOUSE@PSLSTRIVE.ORG FOR AVAILABILITY*
Week 9: August 12th - August 16th *PLEASE EMAIL ALEX AT AWOODHOUSE@PSLSTRIVE.ORG FOR AVAILABILITY*
Week 10: August 19th - August 23rd *PLEASE EMAIL ALEX AT AWOODHOUSE@PSLSTRIVE.ORG FOR AVAILABILITY*
Week 11: August 26th - August 31st *please list AM, PM, or Full Day for each day 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, you will be taken to a payment page to make your deposit. we are asking that families make a $280 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 toattend 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 allyour days upfront.