SUMMER PROGRAM APPLICATION

Application for new & returning summer clients

PLEASE COMPLETE ENTIRE APPLICATION

If you are interested in attending this year’s summer enrichment program or would like additional information regarding the services provided, please complete the summer program application form below.


Child's Personal Information

Child's Name *

Gender *
FemaleMale

Date of Birth* (ie: 01/04/2014)

Street Address *

City*

State *

Zip Code *

Diagnosis*

If Other, Please Specify.


Parent/Guardian Information

Parent/Guardian Names

Street Address (If different than child)

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email Address


Participation

Have you ever attended summer camp at Sara's Garden in the past? *
YesNo

What services are you interested in receiving while at summer camp? (Please check all that apply) *
Intervention ServicesHyperbaric Oxygen TherapyUndecided

Interest Level*

Do you Require Housing*

If Yes, Please Explain


Confirmation

Prove to us you're a human. Please type the text from the image in the field below:
captcha

Contact Us

<p style="text-align: justify;">If you have any questions or would like to receive any additional information on our Sara’s Garden here at Sara's Garden, please feel free to contact us. We would love to address any questions you may have.</p>

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