Enrollment Application

General Information

Registration Application for (please select)*

Full Season ($11,295) Sunday June 28th -Saturday August 8th, 2020
1st Session ($6,995) Sunday June 28th -Saturday July 18th , 2020
2nd Session ($6,995) Sunday July 19th -Saturday August 8th , 2020
Hawaii Trip ($6,995) (Age 15+ Only)

Camper Name*

First

Last

Date of Birth*

Age at Beginning of Camp Session*

Grade entering in Sept. 2020*

Current School*

Home Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Home Phone

Camper's Email Address

Parent 1 Name*

First

Last

Email*

Cell Phone*

Work Phone

Which phone number would you prefer we use?*

Cell Phone
Work Phone

Parent 2 Name

First

Last

Email

Cell Phone

Work Phone

Which phone number would you prefer we use?

Cell Phone
Work Phone

Are Parents divorced or separated?*

Yes
No
Not Applicable

If we need to contact your family, which parent should we reach out to first?

Who has legal custody of the child?*

Parent 1
Parent 2
Both

To Whom should camp mailings be sent?*

Parent 1
Parent 2
Both

To Whom should camp invoices be sent?*

Parent 1
Parent 2
Both

Camper's Primary Diagnosis*

(ADHD, Asperger's Syndrome, etc.)

Camper's Secondary Diagnosis

How did you learn about Camp Sequoia?

If another family referred you to Camp Sequoia, please list them here:

Enrollment Agreement

I agree to the following terms:

ROUTINE MEDICINE*

I agree to the following:

I agree that if my child attends Camp Sequoia, while at camp he will continue to take any medication that he is routinely administered at home. I understand that exceptions will be made only after camp consults with parents and/or prescribing physician.

APPLICATION*

I agree to the following:

I understand that this application is incomplete until a deposit of $1000.00 made payable to Camp Sequoia is received at 3 Ainsley Ct. Newtown, PA 18940. Payment by credit card can be made over the phone with a 3% service charge applied.

RULES & REGULATIONS*

I agree to the following:

The camper (“Camper”) and parent(s) (“Parent”) agree to abide by all of the rules and regulations established by Camp Sequoia (“Camp”) including, without limitation, those relating to enrollment and withdrawal of campers and visitation.

PAYMENT TERMS & CANCELLATIONS*

I agree to the following:

A $1,000 deposit is due with this form. If child is accepted and parents commit to attendance, any future withdrawal will be considered a cancellation and must be submitted in writing. Cancellation penalties will be based on the cancellation date as follows: tuition is fully refundable (less a $250 processing fee) until March 2, 2020; there will be a cancellation fee of $1000 from March 2 to March 31, $2000 from April 1 to April 30, and $3000 from May 1 to May 31 (up to the total cost of tuition). After June 1st no payments will be refunded. Tuition reimbursement insurance is available by TravMark and AMSkier. Please inquire for details.

DISMISSAL OF CAMPER*

I agree to the following:

The Camp reserves the right to dismiss, in its sole discretion, any Camper whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the Camp or his fellow campers or who violates camp rules and regulations. No refunds will be made if a camper is dismissed by the camp.

MEDICAL CARE*

I agree to the following:

Medical care provided by the Camp health care staff is included in the tuition. Parent grants Camp permission to utilize medical treatment (including dental, orthodonture or optical) outside of Camp should the Camp Director(s) (“Director”) deem such treatment necessary for Camper’s well-being. In these cases, all expenses involved will be paid by Parent. Parent must complete Camp Health Form as a condition to Camper’s attendance at Camp.

Parent certifies that Camper is in good health, does not suffer from any physical ailment or disability which requires medical or surgical care or treatment or which would make Camper’s participation in Camp unwise or unsafe.

CAMPER MEDICAL INFORMATION*

I agree to the following:

Parent must inform the Director prior to registration if Camper has received professional counseling or medication for emotional or behavioral modification during the last 12 months. Parent must also inform Director immediately if such care or medication occurs after registration and prior to the camp season. Failure to so inform Director may lead to dismissal of Camper from Camp, and in the event of such dismissal, there will be no refund.

LATE ARRIVAL/EARLY DEPARTURE*

I agree to the following:

No allowance or reduction will be made for late arrival or early departure of Camper without the Director’s consent prior to the camp season. There will be an adjustment made if camper health requires an early departure from Camp at the discretion of the director.

PERMISSION TO PARTICIPATE*

I agree to the following:

Parent grants Camper permission to participate in all Camp activities, excursions, and special outings and understands that accidents and injuries may occur in the natural course of participation in such activities.

IMAGES*

I agree to the following:

Permission is hereby given for Camp to use in promoting the Camp and in other ventures directly relating to the Camp (i) digital, photographic, video, and audio images or likenesses of camper; and (ii)statements, articles, names, art, photographs, audio recordings, films and videos created by Camper or originating from Camp or from a Camp related activity.

BELONGINGS*

I agree to the following:

Camp is not responsible for Camper’s belongings or equipment while in transit or at Camp.

GRATUITIES*

I agree to the following:

Gratuities for staff members are not expected by staff and are at Parental discretion.

COLLECTION*

I agree to the following:

If tuition or fees are not paid in full for Camper, Parent will be liable for all costs of collection, including attorney’s fees.

WAITING LIST*

I agree to the following:

If your child’s age group is filled at the time we receive your enrollment form, we will return your deposit and place your child’s name on our waiting list in order of date received. In the event of a cancellation, waitlisted families will be contacted and offered the opportunity to enroll at that time.

DISPUTES*

I agree to the following:

All claims or disputes asserted by Camper or Parent against the Camp and arising from or related to this Agreement shall be brought and maintained in the courts of the Commonwealth of Pennsylvania (MontgomeryCounty), and Parent expressly submits to the jurisdiction of such courts. The substantive law of the Commonwealth of Pennsylvania will govern such disputes without regard to conflict of law rules. Any individual bringing legal action against Camp, which action is decided in favor of Camp, will be responsible for all legal fees, court costs and out-of-pocket expenses of Camp, its owners and employees.

Parent / Guardian Signature:*

If your son is a returning camper, please check the following box:

My son has attended Camp Sequoia in the past

Parent Questionnaire

We want to do our best to ensure a successful summer for your child. We appreciate your openness as you answer these questions. In answering the questions below, please provide as much information as necessary to help us gain a clear understanding of your child’s specific needs and how we can help them to have a successful camp experience at Camp Sequoia. Please feel free to attach additional pages if necessary, we value any input that will help us to make this summer a success for your child.

Has your child ever attended camp? Has he spent the night away from home without you? How did you and your child handle those nights away?*

What are his feelings about coming to camp this summer?*

Please describe any services/supports your child currently receives (counseling, speech-language therapy, in-home support, etc.)*

Please describe his/her interactions with similar age peers (within 2 years of their age)*

Please describe his challenges relating to functioning in social situations*

Describe his awareness of their social challenges (e.g., Are they aware of how others perceive them, do they think that they are perceived as “different” from their peers?)*

How well does he understand that his actions and words affect others?*

How does he respond to everyday problems, such as changes in schedule, peer conflicts, etc.?*

What are some of your child’s best qualities your child you would like our staff to know?*

Please check behaviors that describe your child. Please check all that apply:*

If Oppositional - Please check which apply:

Home
School
Both Home and School

If Verbally or Physically Aggressive - Please Describe:*

Please rate your child on a 1-5 scale
(1=Needs significant work, 5=Does very well)

Paying attention to others*

Understanding personal space*

Asking questions about others*

Participating in a group*

Making eye contact*

Greeting others*

Understanding the feelings / emotions of others*

Participating in a reciprocal conversation*

Showing empathy*

Asking for help*

Listening*

Personal problem solving*

Taking responsibility for self*

Compromising or negotiating*

Understanding consequences*

Doing chores*

Understanding what people mean by what they say*

Accurately identifying facial expressions and body language*

Anything else we should know to best serve your son this summer?

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Brochure

Virtual Home Visit

Virtual Open House

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Brochure

Virtual Home Visit

Virtual Open House

General Information

Enrollment Agreement

Parent Questionnaire