Child’s Full Legal Name *

Child’s Preferred Name/Nickname

Child’s Date of Birth *

Child’s Address *

Parent’s Name *

Parent’s Address *

Parent’s Phone Number *

Parent’s E-Mail *

Program of Interest * ABA Summer CampNon-ABA/Sibling Summer CampCurrent Patient Field Trip Registration

Requested Date for Camp Registration Assessment *

How did you hear about our Camp? * FacebookBrightFeatsMy Central Florida FamilyFun for Orlando KidsCurrent PatientFriend/FamilyOther

Additional Information