Name of Person Completing this Form *

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Parent/Guardian's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Has your child worked with a Speech-Language Pathologist? *

Yes

No

Has your child been seen by other professionals (e.g., OT, PT, Psychologist/Behaviour Specialist, etc.) *

Yes

No

I give Itsie's Bisies Speech and Language permission to utlize photos of my child for training, website and/or social media. *Names and ages will never be published *

Yes I allow all photos

Yes I allow photos from behind only

No I do not allow photos

I give Itsie's Bitsies Speech and Language permission to take photos of my child to be sent to parent/guardian as part of camp summary

Yes

No

How did you hear about camp?

Web search

Referral

Other

Acknowledgments *

I consent for my child to attend Itsie's Bitsies summer camp(s)

I consent for my child to receive speech and language therapy throughout this summer camp. Therapy is provided in one-on-one, small groups and whole group instruction

As a parent/guardian, I remain legally responsible for any personal actions taken by the above named minor participant(s)

I release Itsie's Bitsies from all unintended harm to my child as a result of day camp activities

I agree that the information contained in this registration form is accurate at this current time