SUMMER CAMP INTAKE FORM

Please complete the following form to ensure we capture important participant information

Parent or Guardian's Name

First Name

Last Name

Parent or Guardian's Phone

(###)

###

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Parent or Guardian's Email

Participants Name

Please enter your child's full name

First Name

Last Name

Participants Age

Participants Grade Level

Entering in the Fall

Emergency Contact (Different from Parent/Guardia)

First Name

Last Name

Emergency Contact Phone

(###)

###

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Medical Information - Allergies

Does your child have any allergies? (Yes/No) If yes, please list all allergies (food, insect stings, medication, etc.) Does your child require an EpiPen or other emergency medication? (Yes/No):

Medical Information - Conditions

Does your child have any chronic medical conditions or anything that would affect physical activity? (Yes/No) If yes, please list all conditions: Are there any specific instructions or precautions we should be aware of for your child's medical condition(s)?

Medical Information - Medications

Does your child take any medications regularly? (Yes/No) If yes, please list all medications, dosage, and frequency: Please provide a labeled container of any medication your child needs during camp.

About Participant - Personality

Please describe your child's personality in a few sentences. Are they outgoing or shy? Do they work well in groups? Does your child have any specific interests or hobbies they'd like to share with us? Are there any social or emotional needs we should be aware of?

About Participant - Learning Style

Does your child learn best by doing activities (kinesthetic), listening (auditory), or seeing things (visual)? (optional) Are there any learning challenges or accommodations we should be aware of?

About Participant - Past Experiences

Has your child attended other camps before? (Yes/No) If yes, please describe their experience(s).

About Participant - Additional Information

Is there anything else you would like us to know about your child to ensure they have a safe and enjoyable experience at Space United Academy Camp?

For more information contact [email protected]

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