Step 1 of 3 33% Child InformationChild's Name First Last Birth Date Session* March 26 - March 30 (full week) March 26 (individual day) March 27 (individual day) March 28 (individual day) March 29 (individual day) March 30 (individual day) Requires one-on-oneYesNoToilet trainedYesNoProgress Report (ESY) - $50YesNoBound Social Story Book - $55YesNoRequesting Morning RespiteYesNoRequesting Afternoon RespiteYesNo Medical InformationPhysician's Name First Last Physician's PhoneMedication Participant is takingMedication is treatment forPhysical RestrictionAllergies (Food & Environmental): Parents & Guardian InformationMother First Last Father First Last Guardian First Last Contact InformationMain ContactMotherFatherGuardianPhone HomePhone CellPhone WorkAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Best Time to ContactTime of day*Morning 8:30am - 12:00pmAfternoon 12:00pm - 5:00pmEvening 5:00pm - 8:30pmBest phone number*CellWorkHomeStatement of Understanding*I (parent/guardian/caregiver) hereby make application to enroll my child in Peak Potential Therapy's Spring Camp. I hereby certify that he/she is of good moral character. I hereby also certify that I have given full disclosure concerning all medical, physical, and psychological conditions which might have relevance to the performance of my child. I also understand that I am liable for information that is false, misleading, or later found to be omitted concerning all such medical, physical, or psychological conditions and all suspensions, expulsions, or adjudications. I have no objection to publicity in conjunction with camp activities that involve my child/ward. I hereby certify that I will assume the necessary financial obligations. I understand and agree that no deductions or rebates will be made if he/she is withdrawn after the start of camp. No refunds of any kind will be provided if the camper fails to report to camp, or in the event of his withdrawal. I (parent/guardian/caregiver) hereby release and hold harmless Peak Potential Therapy LLC including but not limited to Natalie (Holly) M. Reimann and all employees, agents, representatives from any and all claims, cost, damages, and liablities for any injuries sustained by myself or my minor child's or adult's participating in this camp program offered by Peak Potential Therapy. I understand that any fees charged for a program do not include accident, or personal insurance. I have read, understand, and agree to the above Statement of Understanding:YesNoPhotograph Release*I (parent/guardian/caregiver) authorize Peak Potential Therapy to use and reproduce photographs, film and videotape taken of my child and to circulate same for advertising and publicity purposes of any kind.YesNoAdditional Questions & CommentsName*IMPORTANT: By typing your full name, you are providing your legal signature and affirmative consent to all waivers/releases. Children will not be considered registered without their parent/guardian's typed signature.