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 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
Names:

Camper Profile

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:
Do they need support in the restroom?*:
Do they have a history of elopement/bolting away?*:

February Camp Dates (cost for camp is $70 per day)

Tuesday, 2/20, FULL DAY:
Wednesday, 2/21, FULL DAY:
Thursday, 2/22, FULL DAY:
Friday, 2/23 FULL DAY:

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 $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.