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Camp Intake/Placement Form

Signee Information

First Name *

Last Name *

Phone *

Mobile Number *

Email Address *

Address *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Please add all children at the end of form under participant

Does your child receive support in school?*
General Education
Speech Therapy
Specialized Academic Class
Resource Support
Occupational Therapy
Other

If so in what kind? Check all that apply.

Does your child receive support in the community?*
Physical Therapy
Speech
Tutor
Counseling
Occupational Therapy
Other

Does your child have any medical diagnosis? *

If no please put No or N/A

Does your child have any allergies or dietary restrictions?*

If no please put No or N/A

Emergency Contact*

(cannot be same as contact listed above)

Emergency Medical Release: This is to certify I voluntarily furnish medical information on the above designated child to Sensory innovations. I hereby request that in the event that I or the people I authorize for a medical emergency cannot be reached in a timely manner that an official representative from Sensory innovations seek first aid or emergency medical medical care for my child. I further give my consent for an emergency medical facility or physician to administer necessary medical treatment to my child if I am unable to be reached or the situation requires immediate attention. I understand that I am responsible for paying all medical bills.*

Health Insurance Company*

Policy #*

Group #*

Photo Release Form *

I agree as an adult participant, or the Parent/Legal Guardian of a minor participant, that in consideration of being permitted to participate at SENSORY INNOVATIONS LLC, I grant SENSORY INNOVATIONS LLC and its agents, owners, shareholders, directors, partners, employees, volunteers, manufacturers, participants, lessors, affiliates, its subsidiaries, related and affiliated entities, successors and assigns (the “RELEASED PARTIES”) the right and permission to photograph and/or record me or my child in connection with SENSORY INNOVATIONS LLC. I further grant SENSORY INNOVATIONS LLC and all RELEASED PARTIES the right and permission to use the photograph and/or recording for all purposes, including advertising and promotional purposes, in any manner and in any and all media now or hereafter known, in perpetuity throughout the world, without restriction as to alteration. I waive any right to inspect or approve the use of the Photograph and/or Recording. I acknowledge and agree that the rights granted to this release are without compensation of any kind. All Photographs and/or Recordings are exclusive to SENSORY INNOVATIONS LLC. If the participant is a minor, I agree that this Photo Release Form (“RELEASE”) is made on behalf of that minor participant and that all of the releases, waivers, and promises herein are binding on that minor participant. I represent that I have full authority as Parent or Legal Guardian of the minor participant to bind the minor participant to this agreement. I agree that this form will remain in effect until revoked. I understand that it is my responsibility to update this form if I no longer wish to authorize the above uses.

PHOTO PROTECTION RELEASE*

I have read and understand this Photo Release Form agreement listed above and I consent to the terms stated above, I however would like to protect the identity of my child/children by blurring out the child/children in question. By signing below, I grant permission for my child to be photographed, or their images recorded for print or electronic use in promoting Sensory Innovations’ services. This authorization will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I need to notify SENSORY INNOVATIONS, LLC if I want my child/children's identity protected

Is there anything you would like our employees to know about your child?*

(i.e. elopement risk, picky eater, sensitive to different stimuli)

In addition to the guardian listed on this form, I authorize the following individuals to drop off and pick up my child from Sensory Innovations.*

Please make sure name matches Drivers License or State ID

Full Name*

Relationship*

Phone Number*

Full Name*

Relationship*

Phone Number*

Full Name*

Relationship*

Phone Number*

Please enter participants' full names:

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Last Name *

Date of Birth *

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Add Another Name

Sign Here

By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.