Please check the program you are applying for: *

Collaborative Creativity Lab Winter 2025

Teen Mentor

TDC RPG - Weekly Role Play Games

Camp Haven Winter 1 Mini Camp

Camp Haven Winter 2 Mini Camp

Camp Haven Summer Camp

KidsTalk

Smart Practice Body Doubling

Name (Participant) *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Allergies? *

Yes

No

Dietary Restrictions? *

Yes

No

Physical Restrictions? *

Yes

No

Does registrant have any gifts/talents/interests/specific areas of creative and/or intellectual strength?

Yes

No

Does your child have any learning and/or social challenges?

Yes

No

Has your child exhibited physical/verbal aggression within the past year?

Yes

No

Date *

MM

DD

YYYY