Social Skills Camp Registration Form

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June 11-15, 2018 9-12pm
For multiple children please submit a separate form for each.
13720 Midway Rd. Suite 106 Dallas, Texas 75244
469-203-1533 | morganclairemyers@gmail.com

E-mailadres *

Child Name *

Child's Birthdate *

JJJJ

Age *

Male

Female

Current Treating Therapist if any

Special Instructions

How did you hear about us?

Parent Name: *

Address *

Parent Phone number *

Email *

Emergency Contact: Name and Phone Number *

Food restrictions/Diet needs: *

I understand the camp fee is $250 and is due at intake or first session. This includes all supplies needed to facilitate camp. *

Yes

Verplicht

I authorize my child to attend camp with a therapist at Hope Child & Family Center of Texas. Please initial. *

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