Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

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Parent Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Area(s) of Concern *

Articulation Skills

Language Skills

Pragmatic Language/Social Communication

Executive Functioning

Literacy Skills

Summer Camp Offerings *

Elementary (K-5) Speech-Language Camp- 9:00-12:00 p.m. Monday-Friday Fee: $475, Session 2: $380

Intensive R Camp- Tuesdays & Thursdays - 5:00-6:30 p.m. for 6 weeks Fee: $500

Intensive S Camp- Tuesdays & Thursdays- 5:00-6:30 p.m. for 6 weeks Fee: $ 500

Middle School Book Club- Wednesdays 6:00-8:00 p.m. for 6 weeks Fee: $450

Adolescent Executive Functioning Camp- Tuesdays- 6:00-8:00 p.m. for 6 weeks Fee: $450

Summer Session Dates for Week Long Camps *

Please select the desired week (s) for the elementary-aged (K-5) speech-language camp offered Monday-Friday. Groups will be divided by grades K-2 & 3-5.

Session 1: June 23 - June 27, 2025

Session 2: June 30 - July 3, 2025

Session 3: July 7 - July 11, 2025

Session 4: July 14 - July 18, 2025

Session 5: July 21 - July 25, 2025

Session 6: July 28 - August 1, 2025

Emergency Contact Information *

First Name

Last Name

Emergency Contact Phone *

(###)

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Liability Waiver *

I, the undersigned parent/guardian, I, acknowledge that participation in camp at Pediatric & Adolescent Speech Therapy Associates, LLC involves inherent risks, including but not limited to physical activity, group interactions, and the use of speech-language therapy materials. I voluntarily assume all risks associated with my child’s participation, including risks of injury, illness, allergic reactions, or other unforeseen incidents.

I agree

I do not agree

Photo/Video Release *

I give permission for my child’s photo/video to be used in Pediatric & Adolescent Speech Therapy Associates promotional materials and social media.

I agree

I do not agree

Medical Treatment Authorization *

In the event of a medical emergency, I authorize Pediatric & Adolescent Speech Therapy Associates staff to provide first aid and obtain emergency medical treatment for my child. I understand that I am responsible for any medical expenses incurred.

I agree

I do not agree

Release of Liability *

I, on behalf of myself, my child, and our representatives, release and hold harmless Pediatric & Adolescent Speech Therapy Associates LLC, its owners, employees, contractors, and affiliates from any and all claims, liabilities, damages, or expenses arising from my child’s participation in the Camp, including but not limited to personal injury, illness, property damage, or any other loss.

I agree

I do not agree

Date *

MM

DD

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