Program Selection
*
Select a program
Participant's Name
*
First Name
Last Name
Preferred Name
Gender
*
she/her
he/him
them/they
GNB
GNC
2 Spirit
Other
DOB
*
MM
DD
YYYY
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary driver to class
(###)
###
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Media
*
Instagram
Facebook
Twitter
Still Photography
Film-Documentary in progress 2019-2021
Future film documentary 2020-2024
Never Social Media
Need to conference w/TFS
School Coordinator/Leader
First Name
Last Name
Assessment Notes
Does this participant require training programs, assessment notes or signatures from the instructor?
Parent/Guardian Name
*
Please complete for participants 17 years old or younger.
First Name
Last Name
Mailing Address
complete if different from participant
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary phone
*
(###)
###
####
Secondary phone
(###)
###
####
Parent/Guardian
Please complete information for additional parent/guardian/family
First Name
Last Name
Parent Phone
*
(###)
###
####
Secondary Phone
(###)
###
####
Parent/Registering Person Email
*
Support Staff Name
First Name
Last Name
Support Staff Cellphone
(###)
###
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Emergency Contact
*
List an emergency contact
First Name
Last Name
Emergency Contact #1 Phones
*
(###)
###
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Emergency Contact
List an emergency contact
First Name
Last Name
Emergency Contact #2
(###)
###
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Therapeutic Support Staff
NeuroDiversity
Please help guide us in support.
Spectrum Participant Assessment
*
Please provide a brief cognitive, emotional, verbal, social and physical development synopsis for instructor.
Motor Challenges
Does participant have any challenges with motor, coordination, movement, strength, stability or muscle control?
Personality
*
Previous Injuries
Allergies
Visual Impairments
*
Dietary Restrictions
Handedness
*
What is the dominate hand
Please describe physical body development (muscle tone/bone development/growth development)
*
Please share effective support techniques during vulnerable and challenging times.
*
Please share learning milestones in your child's life
Policy or Certificate No.
*
Insurance Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insurance Phone
*
(###)
###
####
Primary Care Physician (PCP)
*
PCP phone
*
(###)
###
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Preferred Hospital/ER
*
Questions or Comments?
Household Administrator/Communicator/Logistics Guru
*
Please help us communicate effectively! Who will be the point person in the family to communicate about camp? (Note: the point person is not always the person registering) Who should we include on communication threads?
Please check all forms of social media you consent TayloredFit Solutions to using and being used for this participant.