Parent's First Name *

Child's First and Last Name *

Date of birth *

My child is potty trained. *

Yes

Does your child have any allergies? *

Yes

If you answered yes above, please explain below:

If my child is unable to follow instructions or prompts in a group of 4-6 children, I understand I will need to provide an additional adult aide to help them participate. *

Yes

Phone *

Email *

Do you have any concerns about your child, that you'd like to be addressed in this summer camp? Please also include if they have any confirmed or suspected diagnoses or additional needs.

How did you hear about our camp? *

We are currently enrolled in services with one of the therapists

My child's therapist (who is not hosting the camp)

Announcement in FB group

Social media post

My child's school/teacher

Other

We will not be collecting payment until you speak with Ms. Molly and we have met our enrollment numbers.

By checking this box, I consent to receive non-marketing text messages from Moving and Grooving Pediatric Physical Therapy about offerings relating to my child's development. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Moving and Grooving Pediatric Physical Therapy at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.