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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